THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


GIFT 
tors.  Lawrence  Stuppy 


BLOOD  AND  URINE  CHEMISTRY 


2  3 

PLATE   I. — STANDARD   WEDGES. 

1.  Standard  I'hcnolsulphonephthalein   Wedge. 

2.  Standard  Uric   Acid   Wedge. 

3.  Standard  Nitrogen  Wedge. 

4.  Standard  Cholesterol    Wedge. 


THE  NEWER  METHODS 
OF 

BLOOD  AND  URINE 
CHEMISTRY 


BY 

R.  B.  H.  GRADWOHL,  M.D. 

DIRECTOR    OF    THE    GRADWOHL    LABORATORIES,    CHICAGO    AND    ST.    LOUIS;    DIRECTOR 
OP  THE  PASTEUR  INSTITUTE  OF  ST.  LOUIS. 


AND 


A.  J.  BLAIVAS 

FORMERLY    ASSISTANT    IN    SAME;    FORMERLY    ASSISTANT     IN     CHEMICAL     LABORA- 
TORY,  ST.    LUKE'S    HOSPITAL,    NEW    YORK    CITY. 


SECOND  EDITION 


WITH  SEVENTY-FIVE  ILLUSTRATIONS  AND 
FOUR  COLOR  PLATES 


ST.  LOUIS 
C.  V.  MOSBY  COMPANY 

1920 


COPYRIGHT,  1S)17,  1920,  BY  THE  C.  V.  MOSBY  COMPANY 


Press  ol 

C.  V.  Mosby  Company 
St.  Louis 


QV 


TO 
WILLIAM  MARION  REEDY 

AN  ESTEEMED  FRIEND 


PREFACE  TO  SECOND  EDITION 

A  number  of  new  facts  in  technic  and  interpretation  have 
been  developed  since  the  time  of  appearance  of  our  first  edition. 
These  facts  have  been  incorporated  into  the  present  volume. 
We  are  pleased  to  note  the  great  interest  that  has  been  awakened  in 
blood  chemistry  among  practical  men  both  in  the  laboratory  and 
clinic.  If  our  modest  contribution  to  the  literature  has  in 
any  way  served  to  assist  in  the  development  of  this  interest,  then 
truly  we  will  feel  that  our  efforts  have  not  been  in  vain. 

At  this  time  and  in  this  place  we  wish  to  express  our  thanks 
for  the  generous  reception  given  the  first  edition  by  the  profes- 
sion. We  also  wish  to  thank  our  publishers,  The  C.  V.  Mosby 
Company,  for  their  splendid  helpfulness  in  the  preparation. 

E.  B.  H.  G. 
A.  J.  B. 

St.  Louis,  Mo. 


PREFACE  TO  FIRST  EDITION 

The  present  work  was  undertaken  in  response  to  a  demand  from 
our  many  professional  friends  who  have  become  keenly  inter- 
ested in  this  line  of  laboratory  investigation.  "We  lay  but  little 
claim  to  originality  but  feel  that  if  we  have  collected  the  major 
part  of  the  information  that  is  so  widely  scattered  throughout 
the  journal  literature  of  the  past  three  or  four  years,  and  boiled 
it  down  into  a  readily  digested  form,  our  labors  will  not  have 
been  in  vain.  The  investigations  in  blood  chemistry  are  pro- 
ceeding rapidly  so  that,  of  necessity,  this  sort  of  book  will  be 
difficult  to  keep  up-to-date.  We,  therefore,  ask  for  the  indul- 
gence of  those  who  are  insistent  upon  the  very  last  word. 

It  will  be  noted  that,  in  the  main,  we  have  given  but  one 
method  for  each  test.  We  have  done  this,  because  we  believe  we 
know  what  the  majority  of  the  practical  workers  along  this  line 
judge  the  best  test  to  be :  besides,  we  see  no  reason  for  describing 
tests  that  time  and  experience  have  proved  fallacious  or  too  com- 
plicated. The  work  in  hand  gives  the  tcchnic  just  as  we  carry 
out  our  routine  and  research  work  in  our  laboratories. 

R.  B.  H.  G. 
A.   J.   B. 

St.  Louis,  Mo. 


CONTENTS 


PART  I. 
TECHNIC  OF  BLOOD  CHEMISTRY. 

CHAPTER  I.                                                     PAGE 
GENERAL   CONSIDERATIONS 17 

CHAPTER  II. 
SUGAR   IN    BLOOD 28 

CHAPTER  III. 
CREATININE 34 

CHAPTER  IV. 
CREATINE 36 

CHAPTER  V. 
URIC  ACID 37 

CHAPTER  VI. 
UREA   . 42 

CHAPTER  VII. 
NONPROTEIN  NITROGEN 47 

CHAPTER  VIII. 
CHOLESTEROL 50 

CHAPTER  IX. 
TOTAL  SOLIDS 53 

CHAPTER  X. 
TOTAL  NITROGEN 54 

CHAPTER  XI. 
CHLORIDES 57 

CHAPTER  XII. 
LIPOIDS ;'    ....... 59 

CHAPTER  XIII. 

TESTS    FOR    ACIDOSIS    IN    BLOOD ,     : 61 


1 2  CONTENTS 

PART  II. 
CHEMICAL  ANALYSIS  OF  URINE. 

CHAPTER  XIV. 
TOTAL  NITROGEN 80 

CHAPTER  XV. 
UREA        , 83 

CHAPTER  XVI. 
AMMONIA 86 

CHAPTER  XVII. 
TOTAL  ACIDITY 88 

CHAPTER  XVIII. 
URIC  ACID     . 


CHAPTER  XIX. 

CREATININE 


CHAPTER  XX. 
CREATIVE 94 

CHAPTER  XXI. 

PllENOLSULPIIONEPIITIIALEIN  .      95 


CHAPTER  XXII. 
CHLORIDES 101 

CHAPTER  XXIII. 
GENERAL   ANALYSIS       102 

CHAPTER  XXIV. 
MICROSCOPIC  ANALYSIS  OF  URINARY  SEDIMENTS 125 

CHAPTER  XXV. 

THE  STAINING  OF  BACTERIA  IN  URINE 144 

CHAPTER  XXVI. 
DESCRIPTION  OF  THE  COLORIMETERS    .     .  .  148 


CONTENTS  13 

PART  III. 
BLOOD  FINDINGS  AND  THEIR  INTERPRETATION. 

CHAPTER  XXVII. 
BLOOD  SUGAR 160 

CHAPTER  XXVIII. 
ACIDOSIS        232 

CHAPTER  XXIX. 
BLOOD  CHANGES  IN  GOUT .    . 263 

CHAPTER  XXX. 

BLOOD  CHEMISTRY  AND  NEPHRITIS 274 

CHAPTER  XXXI. 
BASAL  METABOLISM       348 

APPENDIX 
APPENDIX 393 


ILLUSTRATIONS 

PLATE      I. — STANDARD  WEDGES     .     .     .«   .    .    '.    .    .    .    .    .    .  Frontispiece 

PLATE    II. — STANDARD  WEDGES Facing  page    28 

PLATE  III. — URINE  COLOR  EEACTIONS Facing  page  102 

PLATE    IV. — BENEDICT'S  TEST  FOR  SUGAR     ....    .    .     .    Facing  page  106 

FIG.  PAGE 

1.  View  of  one  side  of  chemical  laboratory  showing  balance,  dessicator, 

etc V  -  .. 20 

2.  View  of  another  side  of  chemical  laboratory   showing  Van   Slyke's 

carbon  dioxide  apparatus   and  the   urea   apparatus  set  up   and 

connected  to  the  suction 21 

3.  Blood  chemical  table   showing  urea   apparatus  and  water-bath   used 

for  the  uric   acid   determinations 22 

4.  Showing  a  high  power  centrifuge  placed  so  as  to  economize  space     .  25 

5.  Manner  of  procuring  blood 26 

6.  Gradwohl  tourniquet . 27 

7.  Chemical  blood  bottle 27 

8.  50    c.c.    centrifuge    tube 28 

9.  Ostwald  pipette ......  29 

10.  Graduated  sugar  tube 29 

11.  Showing  sugar  tube  immersed  in  a  beaker  of  water 30 

12.  Casserole 37 

13.  Showing  centrifuge  tube  attached  to  suction 38 

14.  Volumetric  flask 39 

15.  Showing  the  urea  apparatus  set  up  and  connected  to  suction     ...  43 

16.  Microburner        47 

17.  Apparatus  for  removing  fumes  in   connection  with  nitrogen  deter- 

minations   ' ,.    i* .' 48 

18.  Weighing  bottle  for  total  solids ,     .  53 

19.  Kjeldahl  flask 54 

20.  Digestion    rack 55 

21.  Kjeldahl  apparatus  showing  condenser     .     .    ..'•-..   ,.     .  '.     ,     .     .     •  55 

22.  Graduated  centrifuge  tube ••     •  57 

23.  Showing  operator  saturating  blood  plasma  with  carbon  dioxide     .     .  62 

24.  CO2  apparatus 63 

25.  Dropping  bottles  for  use  in  connection  with  CO2  determination     .     .  64 

26.  C02  apparatus  showing  air  being  forced  out 66 

27.  CO2  apparatus.     Mercury  should  not  go  below  mark  X    .     .     .     .^  .  67 

28.  Phenolsulphonephthalein    ampule 96 

29.  Graduated  syringe  used  for  the  injection  of-  phenolsulphonephthalein  96 

30.  Urinometer 105 

31.  Showing  Benedict's  method  for  the  quantitative  estimation  of  sugar  107 

32.  Graduated    conical    centrifuge    tube 109 

33.  Porcelain  tablet  for  the  determination  of  phosphates 119 

34A.  Centrifuge        125 

34B.  Conical  centrifuge  tube 125 

35A.  Granular    casts                                                  127 


16  ILLUSTRATIONS 

FIG.  PAGE 

35B.  Granular    casts         127 

36.  Hyaline  casts 128 

37A.  Epithelial    casts        128 

37B.  Epithelial    casts        128 

38.  (a)   Blood  casts  (yellow  in  color)  ;    (b)   Pus  casts 129 

39.  Fatty    casts        129 

40A.  Cylindroids 130 

40B.  Cylindroids 130 

41.  Erythrocytes 131 

42.  Human    spermatozoa        131 

43.  "Triple  Phosphate" 133 

44.  Calcium  oxalate  crystals 134 

45.  Calcium  phosphate  crystals 135 

46.  Calcium    sulphate        136 

47.  Calcium  carbonate  crystals 136 

48.  Urie   acid   crystals 137 

49.  Acid  sodium  urate  crystals 138 

50.  Ammonium   urate   crystals 138 

51.  Cholesterol  crystals 139 

52.  Hippuric  acid  crystals 140 

53.  Crystals  of  impure  leucine 141 

54.  Eeprescntation   of   Hellige   colorimeter 149 

55.  Eepresentation   of   Hellige   colorimeter 150 

56.  Representation   of   Hellige   colorimeter 151 

57.  Representation   of   Hellige   colorimeter 152 

58.  Optical  arrangement  of  window  of  colorimeter 153 

59.  Duboscq    colorimeter        155 

60.  Bock-Benedict   colorimeter       158 

61.  Diagram  illustrating  normal  sugar  metabolism 177 

62.  Diagram  illustrating  the  nonutilization  of  sugar  in  diabetes     ....  177 

63.  Diagram  illustrating  excessive  formation  of  sugar  through  nonreten- 

tion  of  glyeogen  in  the  liver 178 

64.  Fridericia  apparatus  for  determination  of  carbon  dioxide  in  alveolar 

air 240 

65A.  The  characteristic  blood  pictures  in  gout,  diabetes,  and  nephritis     .  276 

65B.  The  characteristic  blood  pictures  in  gout,  diabetes,  and  nephritis     .  277 

66.  Blood  and  urine  findings  in  thermic  fever 286 

67.  Respiration  colorimeter  used  at  Bellevuc  Hospital,  New  York     .     .     .  350 

68.  Chart  for  determining  surface  area  of  man  in  square  meters  from 

weight    in    kilograms    and    height    in    centimeters    according    to 

formula , 355 

69.  Atwatcr-Benedict   respiration    colorimeter 359 

70.  Nose  clip;   face  mask;   mouth  piece 369 

71.  Diagram  of  respiratory  valves 370 

72.  Tissot   spirometer        372 

73.  Douglas  bag  method  of  determining  respiratory  exchange         .     .     .  373 

74.  Haldane  gas  apparatus;  Pcarce  sampling  tube 375 

75.  Distillation   apparatus 397 


BLOOD  AND  URINE  CHEMISTRY 


PART  I. 
TECHNIC  OF  BLOOD  CHEMISTRY 


CHAPTER  I. 
GENERAL  CONSIDERATIONS. 

Chemical  analyses  of  blood  have  for  years  been  looked  upon 
as  belonging  to  experimental  physiological  chemistry,  and,  in  no 
sense  of  practical  use  such  as  are  urinary  analyses,  gastric  con- 
tents analyses,  etc.  As  bedside  aids  to  diagnosis,  blood  chemical 
analyses  did  not  really  exist  until  the  epoch-making  work  of 
Folin  brought  the  question  to  the  very  forefront  of  medical  litera- 
ture. It  was  Folin  who  called  attention  to  the  practicability  of 
making  blood  chemical  tests  with  the  idea  in  view  of  aiding  the 
physician  in  diagnosis,  using  ' '  microchemical ' '  methods  which  have 
proved  successful  in  quantitative  analytical  chemistry.  His  work 
has  been  followed  by  others  who  have  simplified  some  of  the  meth- 
ods. Such  eminent  authorities  as  Folin  and  Denis,  Benedict  and 
Lewis,  and  Myers  and  Fine  deserve  much  credit  for  introducing 
these  new  and  reliable  methods  of  clinical  laboratory  technic. 

It  might  be  asked  here,  of  what  practical  use  is  blood  chemistry ; 
what  additional  information  can  it  give  us  over  the  tried  and  ac- 
cepted methods  of  urinary  analyses?  Are  the  data  obtainable 
from  blood  chemical  manipulations  of  more  service  to  the  diag- 
nostician than  are  urinary  findings?  Does  blood  chemistry  give 
data  not  hitherto  obtainable  with  urine  chemical  methods?  We 
must  emphatically  answer  "yes,"  to  both  questions.  In  fact,  we 
trust  that  the  reader  will  recognize,  after  the  perusal  of  this 
book,  that  blood  chemical  analyses  far  surpass  in  value  the  most 

17 


18  BLOOD   AND    URINE    CHEMISTRY 

exact  and  intricate  qualitative  and  quantitative  urinary  analyses. 
We  aim  to  convince  the  reader  that  of  the  two  sets  of  facts,  one 
furnished  by  urine  analyses,  the  other,  by  blood  analyses,  the  lat- 
ter is  of  far  greater  importance.  We  do  not  wish  to  decry,  for 
a  moment,  the  carrying  out  of  routine  urinary  analyses,  nor  do 
we  wish  to  minimize  the  splendid  helpfulness  of  a  good  urine 
analysis:  rather,  do  we  say  that  blood  and  urine  investigations 
should  go  hand  in  hand,  but  that  the  information  obtainable 
from  the  blood  chemical  analysis,  being  of  a  different  character, 
representing  estimation  of  retained  products  of  metabolism 
rather  than  the  estimation  of  pathologically  changed  ingredients 
of  a  fluid  such  as  a  search  for  albumin  or  sugar  in  urine  implies, 
gives  a  far  better  idea  of  metabolic  changes  and  furnishes  a  superior 
basis  for  the  diagnostic  and  prognostic  evaluation  of  a  case  to  that 
furnished  by  the  urine  analyses.  The  blood  chemical  analysis 
tells  us  what  the  blood  is  storing  up,  what  the  kidneys  are  doing  and 
what  they  are  not  doing,  and  also  the  exact  status  of  nitrogenous 
and  carbohydrate  equilibrium.  The  urine  analysis  tells  us  a 
great  deal  about  the  pathology  of  the  kidney  function.  One 
might  be  described  as  an  estimation  of  the  organic  changes  in 
the  kidneys;  the  other,  the  blood  chemical  analysis,  is  an  estima- 
tion of  the  minuticB  of  the  renal  function,  from  a  pathological 
chemical  and  a  pathological  physiological  viewpoint.  Undue  ex- 
cretion of  sugar  in  the  urine  is  pathological,  but  how  about  the 
interpretation  of  the  finding  of  glycosuria?  We  know  that  the 
amount  of  sugar  in  the  blood  gives  a  far  better  picture  of  carbo- 
hydrate metabolism  than  does  the  appearance  of  sugar  in  the  urine. 
Sugar  appears  in  the  urine  in  a  case  of  diabetes  mellitus  purely  as 
an  "overflow"  proposition,  whereas  there  may  be  an  enormous 
sugar  retention  in  the  blood  before  the  kidneys  permit  it  to  leak 
through.  Thus  an  individual  may  have  a  hyperglycemia  long 
before  he  has  a  glycosuria.  There  may  be  a  so-called  prediabetic 
stage  to  which  the  older  writers  often  referred;  only  a  blood 
chemical  estimation  of  sugar  would  detect  this.  Again,  there 
may  be  a  case  of  low  hyperglycemia  and  pronounced  glycosuria 
with  kidneys  in  individual  cases  readily  permeable  to  sugar. 
Glycosuria  in  this  case  would  give  one  no  idea  of  the  low  grade 
of  hyperglycemia.  In  renal  diabetes,  too,  there  is  no  hypergly- 


GENERAL    CONSIDERATIONS  10 

cemia,  simply  a  glycosuria  possibly  due  to  unusual  permeability  of 
the  kidneys  for  the  normal  blood  .sugar,  never  a  hyperglycemia. 
How  could  one  differentiate  then  between  diabetes  mellitus  and 
renal  diabetes  without  a  comparative  blood  and  urine  chemical 
analysis  ? 

We  feel  that  the  subject  has  now  been  sufficiently  worked  out 
to  demand  a  condensation  of  all  the  facts  gleaned  by  blood  chem- 
istry and  their  interpretation  in  clinical  medicine  into  a  small 
textbook  for  the  information  of  those  who  are  interested.  The 
literature  has  appeared  practically  in  only  the  technical  journals, 
principally  the  Journal  of  Biological  Chemistry.  These  articles 
are,  as  a  rule,  inaccessible  to  many  physicians  and  even  to  some 
of  the  laboratory  workers  in  communities  where  there  is  no  medi- 
cal library.  The  writers'  task  is,  therefore,  to  give  fully  the 
best  methods  that  have  been  devised  by  the  workers  in  this  field 
together  with  such  facts  as  they  themselves  have  gleaned  during 
years  of  effort,  together  with  the  most  important  literature  on 
this  question.  The  subject  is  under  close  investigation  and  rapid 
strides  are  being  made.  It,  therefore,  behooves  those  who  are 
interested  in  the  practical  and  scientific  sides  of  medicine  to  keep 
informed  on  all  this  progress.  We  trust  that  our  modest  efforts 
will  assist  in  spreading  the  facts  before  those  not  familiar  with 
them  and  that  others  may  be  stimulated  to  assist  in  this  work  of 
accurately  estimating  bodily  metabolism  in  health  and  in  disease. 

We  shall,  later  on  in  the  work,  give  our  interpretation  of  the 
technical  findings  in  blood  and  urine  chemistry.  Owing  to  the 
wide  interest  in  this  newborn  side  of  laboratory  diagnosis,  we 
wish  to  immediately  take  up  the  question  of  installation  of  the 
laboratory  for  this  sort  of  work  and  the  actual  technic  of  the  tests. 

Installation  of  the  Blood  and  Urine  Chemical  Laboratory. 

We  have  described  in  the  following  pages  the  various  apparatus, 
reagents,  glassware,  etc.,  needed  in  this  work.  We  shall,  as  it  were, 
construct  a  model  laboratory  for  the  reader  in  which  he  may 
most  profitably  pursue  these  investigations.  We  shall  not  enu- 
merate unnecessary  apparatus,  but  shall  endeavor  to  make  the 
wants  of  the  prospective  worker  as  few  as  possible.  Stately  halls, 
marble  columns,  and  lavish  expenditure  do  not  alone  imply  great 
work.  Simplicity,  modesty,  coupled  with  untiring  zeal  and  exact 


20 


BLOOD   AND    URINE    CHEMISTRY 


observation,  have  given  us  what  great  advances  medicine  today 
has  gained,  and  to  that  end  we  will  construct  a  practical  and  in- 
expensive laboratory  for  those  who  contemplate  launching  into 
this  department  of  laboratory  medicine. 

We  will  give  the  essentials  of  equipment  and  the  ideal  of  their 
arrangement,  allowing  the  ingenuity  and  particular  facilities  of 
each  worker  contemplating  taking  up  this  technic  to  work  out 
his  own  arrangement  of  laboratory  furniture,  etc. 

Selection  of  the  Room. — Preferably  a  room  should  be  selected 


Fig.   1. — View  of  one  side  of  chemical  laboratory  showing  balance,  dessica 


tor,  etc. 


with  good  northern  exposure  for  the  accurate  reading  of  the 
colorimeter.  There  should  be  a  well  protected  place  for  the 
chemical  balance;  safe  from  sunlight  and  jarring.  There  should 
be,  also,  a  firm  block  of  wood  arranged  conveniently  for  the  plac- 
ing of  the  centrifuge.  There  should  be  running  water  in  the 
room  for  two  purposes;  one  for  suction  in  running  a  Chapman 
pump,  the  other  for  obtaining  water  for  a  water-bath,  cleaning 
glassware,  etc.  There  should  also  be  a  chemical  hood  with  the 
customary  outlet  for  permitting  vapors  to  escape.  There  should 


GENERAL    CONSIDERATIONS 


21 


also  be  a  convenient,  strongly  constructed  table  for  the  microscope 
and  balance.  This  in  a  general  way  covers  the  arrangement  of 
the  room  for  the  larger  articles.  In  addition  to  these  features, 
there  should  be  shelving  for  the  accommodation  of  the  reagent 
bottles,  with  drawers  and  cupboards  for  the  storage  of  glass- 
ware, tubing,  etc.  The  work  table  should  be  large  enough  to 
permit  from  two  to  six  Bunsen  burners  to  be  placed  in  rows  for 
the  simultaneous  heating  of  blood  specimens. 


Fig.  2. — View  of  another  side  of  chemical  laboratory  showing  Van  Slyke's  carbon  dioxide 
apparatus  and  the  urea  apparatus  set  up  and  connected  to  the  suction. 

For  the  purpose  of  illustrating  several  views  of  a  model  labora- 
tory, we  call  attention  to  Figs.  1  and  2  which  show  the  CQ2  ap- 
paratus, chemical  balance  set  up,  desiccator,  etc.  In  Fig.  3  is 
shown  the  blood  chemical  table  proper,  with  running  water  in 
the  middle  of  same,  the  Chapman  suction  pump,  and  the  water- 
bath  set  up  for  uric  acid  estimations.  It  also  shows  the  arrange- 
ment of  the  cylinders  for  urea  estimation,  a  complete  description 
of  which  will  be  found  in  the  chapter  on  this  subject  (see  p.  43). 


22 


BLOOD    AND    URINE    CHEMISTRY 


Fig.    3. — Blood   chemical   table   showing   urea   apparatus    and 
acid  determinations. 


vater-bath   used   for 


Chemicals  and  Apparatus  Used  in  the  Newer  Chemical  Analysis 
of  Blood  and  Urine. 


It  is  essential  to  have  a  "Hellige"  colorimeter  which  is  de- 
scribed on  page  149  and  a  balance  which  is  accurate  to  one-tenth 
of  a  milligram.  The  Duboscq  and  the  Bock-Benedict  are  likewise 
excellent  colorimeters  (see  pages  154  and  157). 


CHEMICALS, 
Urea  N. 

Urease,   10   gms. 
Mercuric   iodide,    200    gms. 
Potassium  iodide,   100   gms. 
Potassium   hydroxide,    400   gms. 
Amyl  alcohol,   100   c.c. 
Caprylic   alcohol,    25    c.e. 
Hydrochloric  acid,  500  gms. 


APPARATUS. 
Urea  N. 

6  Volumetric  flasks    (1000  c.c.,  500 

c.c.,  250  c.c.),  2  of  each. 
50  Test   tubes   about   200   mm.    long 
and  of   diameter  such   that   will 
slip  into  100  c.c.  graduate. 

2  Nests  of  beakers  from  50  c.c.  to 
1000  c.c.  capacity. 

1  Sulphuric  acid  wash  bottle. 

G  Bunseri  burners. 

6  Tripods. 

6  Pieces  wire  gauze,  asbestos  center. 

1  Thermometer. 


GENERAL    CONSIDERATIONS 


23 


CHEMICALS. 
Urea  N — Cont  'd 


Uric  acid. 

Acetic    acid,    500    gms. 
Alumina  cream,  250  gms. 
Potassium   cyanide,   30    gms. 
Silver  nitrate,  30  gms. 
Magnesium    sulphate,    50    gms. 
Ammonium  chloride,  100  gms. 
Ammonia    (cone.),   500   gms. 
Uric   acid    (Kahlbaum),    %   gm. 
Sodium   tungstate,   100   gms. 
Hydrogen  disodium  phosphate, 

25  gms. 
Dihydrogeu   sodium    phosphate, 

5  gms. 
Sodium  carbonate,  500  gms. 


Sugar. 

Pure  glucose,  25  gms. 
Picramic  acid,  %  gm. 
Picric  acid,  100  gms. 

Creatine  and  Creatinine. 
Potassium  bichromate,  25  gms. 
Creatinine,   *£  gm. 
Sodium    hydroxide,    500    gms. 


APPARATUS. 
Urea  N  —  Cont  'd 

3  Graduates,  100  c.c.  (no  lips),  non- 
graduated. 

3  Graduates,  100  c.c.  (no  lips),  grad- 

uated. 

4  Volumetric  flasks  (50  c.c.). 

9  Pipettes,  5  c.c.,  20  c.c.,  25  c.c.  (3 

of  each). 
6  Two-hole    rubber    stoppers    to    fit 

graduates. 
1  Twenty-four    foot    tubing    to    fit 

holes. 

1  Suction  pump. 
1  Desiccator. 
1  Wash  bottle  and  connection. 

Uric  acid. 
4  Cylinders,     (100    c.c.).       (Gradu- 

ated.) 

6  Casseroles,  (375  c.c.  capacity). 
12  Stirring  rods,  (6  in.). 
1  Water-bath. 

G  Funnels,  about  4  in.  diameter. 
100  Filter    papers    (for    above    fun- 

nels) . 

6  Centrifuge  tubes,  (15  e.c.,  conical). 
1  Centrifuge. 
8  Pipettes,  2  c.c.  and  10  c.c.  —  four 

of  each. 
1  Wash  bottle  and  connection   (for 

hot  water). 

Sugar. 

6  Sugar  tubes,  graduated  to  20  c.c. 
3  Pipettes,  1  c.c.  and  3  c.c. 


Creatine  and  Creatinine. 
Graduates,   10   c.c.,   25   c.c.  —  4 


of 


each. 

3  Pipettes,  1  c.c.  graduated  1/100. 
12  Centrifuge  tubes,  15  c.c.  and  50 

c.c.  —  six  of  each. 
1  Autoclave. 


C02  Combining  Power  of  Plasma. 
Phenolphthalein,  10  gms. 
Sulphuric  acid,  500  gms. 
Mercury,  5  Ibs. 
Caprylic  alcohol,  30  c.c 


C02  Combining  Power  of  Plasma. 
1  Van  Slyke  apparatus. 
1  Heavy  stand  and  rod. 
1  6-ft.  Heavy  suction  tubing. 
1  Iron  -od  and  connection. 


24 


BLOOD   AND    URINE    CHEMISTRY 


CHEMICALS. 

C02    Combining   Power   of   Plasma — 
Cont  'd. 


Nonprotein   Nitrogen. 
Potassium  sulphate,  50  gms. 
Copper  sulphate,   50   gms. 
Trichloracetic  acid,  100  c.c. 
Kaolin,  25  gms. 


Cholesterol. 
Chloroform,  500  c.c. 
Acetic  anhydride,  50  e.c. 
Cholesterol  or  naphthol, 
Green  T>,  1  gm. 
Ether,   250   c.c. 
Alcohol   (redistilled),  500  c.c. 

Total  Solids. 


Chlorides. 

Colloidal   iron,    50    c.c. 
Potassium  chromate,  25  gms. 
Silver  nitrate,  10  gms. 
Ferric  ammonium  sulphate,  100  gms. 
Nitric  acid,  500  gms. 
Ammonium   thyocyanatc,   10   gms. 

Total  Nitrogen. 
Congo  red,  5  gms. 
Peroxide  of  hydrogen,  50  c.c. 


Phenol  phthalein. 
Phenolsulphonphthalein  in  1  c.c. 
ampules — 3. 

Ammonia. 
Included  in  foregoing. 


APPARATUS. 

C02    Combining   Poicer   of   Plasma — 
Cent  'd. 

1  Large  clamp  and  connection. 

2  Rings. 

6  Dropping  bottles  (with  rubber  nip- 
pies). 

1  Separating  funnel. 

1  Apparatus  for  saturating  blood 
plasma  (consisting  of  bottle  filled 
with  glass  beads  and  connection). 

Nonprotein  Nitrogen. 

3  Microburners. 

1  Apparatus    for    removing    fumes 

(large  bottle,  2 -hole  rubber  stop- 
per and  connection,  1  stand  and 
connection). 

Cholesterol. 

3  100  c.c.  graduated  flasks. 
3  25  c.c.  beakers. 

2  10  c.c.  glass-stoppered,  graduated 

cylinders. 


Total  Solids. 

2  Weighing   bottles    (glass   stoppers 

and  block  of   filter   and  connec- 
tion) . 

Chlorides. 

3  Evaporating    dishes,    50    c.c.    ca- 

pacity. 

2  Volumetric  flasks,  25  c.c.  capacity. 
2  Burettes,  stand  and  connection. 


Total  Nitrogen. 
2  Kjeldahl  flasks. 

1  Digestion  rack,  consisting  of  out- 

let   for    fumes,    distilling    outfit, 
and   receiving  bottle. 

Phenolphthalein. 

2  Graduates,  1000  c.c. 

1  Accurately  graduated  1  c.c.  glass 
syringe  with  needles. 

Ammonia. 
Included   in   foregoing. 


GENERAL    CONSIDERATIONS  25 

A  high  power  centrifuge  is  advisable,  one  that  can  carry  15 
c.c.,  50  c.c.,  and  100  c.c.  centrifuge  tubes.  Fig.  4  illustrates  a  con- 
venient method  of  placing  the  centrifuge  so  as  to  economize  space. 
The  centrifuge  is  set  on  heavy  blocks  of  wood  so  as  to  avoid  un- 
due vibration.  The  work  table  is  hinged  so  as  to  utilize  the 
space  occupied  by  the  centrifuge. 


Fig.   4. — Showing  a  high  power  centrifuge  placed  so  as  to   economize   space. 

Manner  of  Procuring  and  Handling  of  Blood. 

The  withdrawal  of  blood  can  best  be  accomplished  by  following 
the  method  of  one  of  the  writers  (Gradwohl)  in  obtaining  blood 
for  the  Wassermann  reaction  (see  Fig.  5),  which  is  as  follows: 

Expose  the  bend  of  the  elbow  where  a  prominent  vein  can  usu- 
ally be  found.  In  women  and  men  with  a  good  deal  of  adipose 
tissue,  these  veins  are  sometimes  not  visible.  In  such  cases,  select 
the  wrist  or  back  of  the  hand.  Place  a  tourniquet,  either  bandage 
or  rubber  tubing,  above  the  bend  of  the  elbow.  The  patient  is 
then  instructed  to  double  his  fist,  which  still  further  assists  in 


26 


BLOOD    AND    URINE    CHEMISTRY 


distending  the  veins  between  the  fist  and  the  portion  of  the  arm 
upon  which  the  tourniquet  is  tied. 

The  skin  over  the  vein  is  then  thoroughly  cleansed  by  rubbing 
vigorously  with  alcohol.  Although  iodine  is  a  good  antiseptic, 
it  is  not  advisable  to  use  it,  as  it  leaves  a  dark  stain  on  the  skin 
which  obscures  tlie  vein  and  makes  it  difficult  to  find. 

The  needle  is  then  removed  from  the  test  tube  and  plunged 
into  the  vein,  procuring  at  least  25  c.c.  of  blood  in  this  manner. 


Fig.  5.— M 


At  this  point  nve  might  call  attention  to  the  usefulness  of  the 
Gradwohl  tourniquet  (Fig.  6)  in  blood  withdrawal.  This  gives 
uniform  compression  and  readily  permits  one  to  liberate  the 
tourniquet  without  dislodging  the  needle  from  the  vein.  By 
alternately  releasing  and  clamping  the  tourniquet,  sufficient  blood 
may  be  obtained  by  this  means  for  a  complete  chemical  analysis. 
Massaging  upwards  also  facilitates  the  flow  of  blood. 

The  blood  should  be  taken  in  the  morning,  before  breakfast.  In 
other  words,  if  it  is  not  convenient  to  take  the  blood  before  the 


GENERAL    CONSIDERATIONS 


27 


usual  breakfast  hour,  then  it  may  be  taken  later,  but  the  patient 
must  not  eat  anything  until  after  the  blood  is  taken.  The  reason 
for  this  is  that  all  data  on  the  normal  standards  and  the  patho- 
logical changes  have  been  obtained  with  blood  obtained  under 
these  conditions.  Therefore,  for  the  sake  of  uniformity,  we 
would  recommend  this  method. 

Amount  of  Blood  Needed. — Twenty-five  cubic  centimeters  of 
blood  should  be  withdrawn  for  a  complete  analysis. 


Fig.  6. — Gradwohl  tourniquet. 


This  blood  is  allowed  to  run  from  the  needle  into  small  chemi- 
cal bottles  (see  Fig.  7)  containing  10  drops  of  20  per  cent  solu- 
tion of  potassium  oxalate.*  This  oxalate  should  be  previously 
dried  in  the  oven  overnight  at  100°  C. 


Fig.   7. — Chemical  blood  bottle. 

As  soon  as  possible  after  the  25  c.c.  of  blood  have  been  obtained, 
one  should  quickly  close  the  bottle  and  begin  shaking  vigorously 
so  as  to  complete  the  defibrination  of  the  blood  which  the  potas- 
sium oxalate  partially  accomplishes.  Do  not  stop  shaking  until 
perfect  fluidity  of  the  blood  has  been  obtained.  After  defibrina- 
tion of  the  blood,  the  process  of  chemical  analysis  should  begin. 


*Some  workers  claim  that  sodium  oxalate 


CHAPTER  II. 
SUGAR  IN  BLOOD. 

It  is  advisable  to  begin  the  blood  chemical  analysis  by  estima- 
tion of  sugar  and  creatininc  first,  because  these  two  substances 
most  quickly  deteriorate  and  hence  their  estimation  should  be 
begun  at  once.  Urea  and  uric  acid  determinations  can  be  done 
later. 

Take  a  50  c.c.  centrifuge  tube  (Fig.  8)  and  place  in  it  20  c.c. 
of  distilled  water.  Suck  up  5  c.c.  of  the  blood  into  an  Ostwald 


Fig.   8. — 50  c.c.   centrifuge  tube. 

pipette  (Fig.  9)  and  allow  it  to  run  into  the  bottom  of  the  centri- 
fuge tube,  below  the  water.  Wash  the  pipette  by  alternately  draw- 
ing up  and  blowing  down  this  blood  and  water  mixture.  Stir 
the  mixture  to  lake  the  cells.  Add  0.5  gram  dry  picric  acid 
which  precipitates  the  protein.  Stir  thoroughly.  Allow  it  to  stand 
10  to  15  minutes.  Stir  occasionally.  Place  in  centrifuge  and 
run  for  5  minutes  at  about  1500  revolutions  per  minute.  Now  re- 
move the  tube  from  the  centrifuge  and  filter  the  mixture  through 
a  small  filter  paper  into  a  clean,  dry  test  tube.  Part  of  this 
filtrate  is  used  for  the  sugar  estimation  and  part  for  the  creatin- 
ine  estimation.  Take  3  c.c.  of  the  filtrate  for  the  sugar  test,  the 
remainder  being  reserved  for  the  creatinine  test.  Place  3  c.c.  of 
the  filtrate  in  a  sugar  tube  (Fig.  10)  ;  add  1  c.c.  of  saturated  solu- 

28 


A 


PLATE   II. — STANDARD   WEDGES. 

1.  Standard   Picramic   Acid    Wedge. 

2.  Standard   Bichromate    (Normal)    Wedge. 

3.  Standard  Creatinine  Wedge. 


SUGAR   IN    BLOOD 


29 


tion  of  sodium  carbonate,1  and  mix.  Immerse  the  test  tube  contain- 
ing this  mixture  in  a  large  beaker  of  water  and  then  boil  the  beaker 
over  a  free  flame  for  15  minutes  (Fig.  11),  after  which  it  is  al- 


ct 


cc 

•  10 


Fig.    9. — Ostwald   pipette. 


Fig.   10.- — Graduated  sugar  tube. 


lowed  to  cool.  The  final  step  in  the  test  is  to  so  dilute  this  cooled 
solution  with  distilled  water  that  it  will  be  weaker  in  color  than 
the  standard  picramic  acid  solution  with  which  it  is  to  be  com- 
pared in  the  colorimeter.  To  this  end  we  dilute  it  to  10,  15,  or 


^This  is  prepared  by  dissolving   220   grams   of  anhydrous  sodium   carbonate   in    1000   c.c. 
of   distilled  water. 


30 


BLOOD   AND    URINE    CHEMISTRY 


20  c.c.  [see  marks  upon  the  graduated  sugar  tube  (Fig.  10)].  It 
must  be  remembered  that  in  normal  cases  a  dilution  up  to  10  c.c.  will 
suffice,  but  beyond  this  it  is  often  necessary  to  dilute  to  15  c.c. 
or  even  20  c.c.  in  cases  of  hyperglycemia.  It  is  now  compared 


Fig.   11. — Showing  sugar  tube  immersed  in  a  beaker  of  water. 

in  the  colorimeter  with  the  wedge  of  standard  picramic  acid. 
(See  Plate  II  for  the  color  of  the  standard  picramic  acid  wedge.) 
The  standard  picramic  acid  solution  is  a  staple  solution  and 
is  made  as  follows:  Dissolve  0.1  gm.  picramic  acid  and  0.2  gm. 
anhydrous  sodium  carbonate  in  30  c.c.  warm  distilled  water  and 
dilute  to  1  liter. 


SUGAR   IN   BLOOD 


3J 


Example  1. — Now  let  us  assume  that  the  reading  with  the  colori- 
meter was  52.    If  your  dilution  is  10,  subtract  52  from  100  which 
equals  48.     With  a  dilution  of  10,  multiply  this  by  0.002  which  - 
equals  0.096,  which  means  0.096%  of  sugar  present.    This  would  be 
a  normal  finding. 

Example  2. — Let  us  assume  that  the  reading  is  41  and  the 
dilution  is  25.  41  from  100  equals  59.  Multiply  this  by  0.005  which 
equals  0.295  (hyperglycemia).  In  other  words,  with  a  dilution 
of  10,  multiply  the  difference  between  the  reading  and  100  by 
0.002;  if  dilution  is  15,  multiply  the  difference  by  0.003;  if  the 
dilution  is  20,  multiply  by  0.004;  if  the  dilution  is  25,  multiply 
by  0.005;  etc. 

Identical  results  may  be  obtained  by  using  the  data  presented 
in  Table  I,  providing  the  estimation  was  made  on  the  basis  of  a 
dilution  of  10.  If  it  was  diluted  to  15  c.c.,  multiply  the  result  by 
1.5 ;  to  20  c.c.,  multiply  by  2 ;  etc. 

TABLE  P 

ESTIMATION  OF  BLOOD  SUGAR  WITH  HELLIGE  COLORIMETER 


COLORI- 

BLOOD 

COLORI- 

BLOOD 

COLORI- 

BLOOD 

METRIC 

SUGAR  IN 

METRIC 

SUGAR  IN 

METRIC 

SUGAR  IN 

READING 

PER   CENT 

READING 

PER   CENT 

READING 

PER   CENT 

25 

0.150 

45 

0.110 

65 

0.070 

26 

0.148 

46 

0.108 

66 

0.068 

27 

0.146 

47 

0.106 

67 

0.066 

28 

0.144 

48 

0.104 

68 

0.064 

29 

0.142 

49 

0.102 

69 

0.062 

30 

0.140 

50 

0.100 

70 

0.060 

31 

0.138 

51 

0.098 

71 

0.058 

32 

0.136 

52 

0.096 

72 

0.056 

33 

0.134 

53 

0.094 

73 

0.054 

34 

0.132 

54 

0.092 

74 

0.052 

35 

0.130 

55 

0.090 

75 

0.050 

36 

0.128 

56 

0.088 

76 

0.048 

37 

0.126 

57 

0.086 

77 

0.046 

38 

0.124 

58 

0.084 

78 

0.044 

39 

0.122 

59 

0.082 

79 

„  0.042 

40 

0.020 

60 

0.080 

80 

0.040 

41 

0.118 

61 

0.078 

81 

0.038 

42 

0.116 

62 

0.076 

82 

0.036 

43 

0.114 

63 

0.074 

"83 

0.034 

44 

0.112 

64 

0.072 

84 

0.032 

'Myers   and    Fine: 
York,   1915. 


Chemical    Composition    of   the    Blood   in    Health   and    Disease,   New- 


32  BLOOD   AND    URINE    CHEMISTRY 

The  authors  wisli  to  caution  tlie  beginner  in  this  work  to  make 
his  readings  as  quickly  as  possible  as  these  colors  deteriorate 
very  rapidly,  rendering  a  difference  of  from  1  to  3  points  on  the 
scale  of  the  colorimeter. 

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SUGAR   IN   BLOOD  33 

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Steustrom :     Biochem.  Ztschr.,  1914,  vol.  Iviii,  pp.  472-482. 
Stilling:     Arch.  f.  exper.  Path.  u.  Therap.,  vol.  Ixvi,  p.  238. 
Strouse:     The  Accurate  Clinical  Study  of  Blood  Sugar,  Bull.  Johns  Hopkins 

Hosp.,  1915. 

Tachu:    Arch.  f.  klin.  Med.,  1911,  vols.  cii  and  civ,  p.  437. 
Tachu:      Ebenda,  vol.  civ,  p.  437. 
Takataschi:     Biochem.  Ztschr.,  vol.  xxxvii. 

Taylor  and  Hutton:     Jour.  Biol.  Chem.,  1915,  vol.  xxii,  p.  63. 
Tileston   and  Comfort:      Arch.  Int.  Med.,   1914,  vol.  xiv,  p.   620. 
von  Hess:      The  Condition   of   the   Sugar   in   the   Blood,  Jour.   Pharm.   and 

Exper.  Therap.,  1914. 

von  Noorden:     Die  Zuckerkrankheit,  Berlin,  1912,  p.  59. 
Weiland,  Eppinger,  Falta  and  Rudinger:      Deutsch.  Arch.  f.  klin.  Med.,  vol. 

Ixvi. 
Woodyatt,  Sansum  and  Wilder:     Jour.  Am.  Med.  Assn.,  1915,  vol.  Ixv,  p.  2067. 


CHAPTER  III. 


CREATININE. 

We  begin  this  estimation  by  taking  the  remaining  nitrate  as 
already  described  in  the  sugar  estimation,  i.e.,  that  part  of  the 
nitrate  left  after  we  took  the  3  c.c.  for  the  sugar  test.  Take  10 
c.c.  of  this  nitrate.  (At  this  point  we  wish  to  emphasize  the  fact 
that  in  this  test  the  unknown  and  the  standard  solution  must  be 
made  up  at  the  same  time  to  prevent  the  development  of  the  color 
in  one  case  faster  than  that  in  the  other,  thereby  obtaining  in- 
correct results.)  To  the  10  c.c.  filtrate  add  0.5  c.c.  of  a  10%  sodium 
hydroxide  solution,  and  to  20  c.c.  of  the  standard  creatinine  solu- 
tion add  1  c.c.  of  10%  sodium  hydroxide.  (See  Plate  II  for  the 
color  of  the  standard  creatinine  wedge.)  Allow  both  to  stand  10 
minutes  and  read  in  the  colorimeter. 

TABLE  II1 

ESTIMATION  OF  CREATININE  IN  THE  BLOOD    WITH   THE   HELLIGE  COLORIMETEK 


COLOHI- 
METRIC 
READING 

CREATININE 
MOMS.  PER 
DILUTION 
OF  100  C.C. 

COLORI- 
METRIC 
READING 

CREATININE 
MGMS.  PER 
DILUTION 
OF  100  C.C. 

COLORI- 
METRIC 
READING 

CREATININE 
MGMS.  PER 
DILUTION 
OF  100  C.C. 

40 

0.80 

57 

0.55 

74 

0.31 

41 

0.78 

58 

0.54 

75 

0.30 

42 

0.77 

59 

0.52 

76 

0.28 

43 

0.75 

CO 

0.51 

77 

0.27 

44 

0.74 

61 

0.50 

78 

0.25 

45 

0.72 

62 

0.48 

79 

0.24 

46 

0.71 

63 

0.47 

80 

0.22 

47 

0.70 

64 

0.45 

81 

0.21 

48 

0.68 

65 

0.44 

82 

0.20 

49 

0.67 

66 

0.42 

83 

0.18 

50 

0.65 

67 

0.41 

84 

0.17 

51 

0.64 

68 

0.40 

85 

0.15 

52 

0.62 

69 

0.38 

86 

0.14 

53 

0.61 

70 

0.37 

87 

0.12 

54 

0.60 

7 

0.35 

88 

0.11 

55 

0.58 

72 

0.34 

89 

0.10 

56 

0.57 

73 

0.32 

90 

0.09 

»The  table  here  given  must  be  used  when  N/4  bichromate  is  used  as  a  standard.  From 
Myers  and  Fine:  Chemical  Composition  of  the  Blood  in  Health  and  Disease,  New 
York,  1915. 

34 


CREATININE  35 

The  standard  solution  of  creatinine  is  made  by  dissolving  15 
mgms.  of  pure  creatinine  in  1000  c.c.  of  a  saturated  solution  of 
picric  acid. 

The  formula  for  the  computation  of  this  result  is  as  follows: 
89  minus  reading  x  0.0179  x  5  =  mgms.  of  creatinine  per  100  c.c. 
of  blood. 

Example. — Let  us  assume  the  reading  in  an  experiment  is  64. 
Then  89  minus  64  =  25x0.0179  =  0.4475x5  =  2.2375  mgms.  (nor- 
mal). 

Slightly  less  accurate  results  than  these  may  be  obtained  by 
using  N/4  bichromate  of  potash  solution.  (See  Plate  II  for 
the  color  of  the  standard  bichromate  wedge.)  When  using  this 
solution  as  a  standard  the  nitrate  is  treated  as  in  the  preceding, 
and  the  result  is  multiplied  by  5.  The  reader  is  referred  to  Table 
II  (page  34)  which  should  be  used  when  N/4  potassium  bichromate 
is  used  as  a  standard. 

The  standard  potassium  bichromate  is  made  by  dissolving  12.28 
grams  of  potassium  bichromate  in  distilled  water  and  making  up 
to  1  liter. 

The  authors  recommend  the  pure  creatinine  over  the  latter 
method  inasmuch  as  repeated  experiences  with  the  two  methods 
give  greater  percentages  of  accurate  findings  with  the  former. 

BIBLIOGRAPHY. 

Chace  and  Myers:     Jour.  Am.  Med.  Assn.,  1916,  vol.  Ixvii,  p.  932. 

Folin:      Jour.  Biol.  Chem.,  1914,  vol.  xvii,  p.  475. 

Folin  and  Denis:     Jour.  Biol.  Chem.,  1912,  vol.  xii,  p.  141;   Ibid.,  1914,  vol. 

xvii,  pp.  475,  487,  and  493. 
Foster:     Arch.  Int.  Med.,  1915,  vol.  xv,  p.  356. 
Myers   and   Fine:      Jour.   Biol.   Chem.,   1915,   vol.   xx,   p     391. 
Myers  and  Lough:     Arch.  Int.  Med.,  1915,  vol.  xvi,  p.  536. 
Woods:     Arch.  Int.  Med.,  1915,  vol.  xvi,  p.  577. 


CHAPTER  IV. 
CREATINE. 

For  the  determination  of  creatine  (and  creatinine) ,  pipette  with 
an  Ostwald-Folin  pipette  1  or  2  c.c.  of  the  remaining  filtrate 
from  the  sugar  estimation  into  a  small  test  tube  or  10  c.c.  graduate, 
and  autoclave  at  twenty  pounds  pressure  for  twenty  minutes.  At 
the  end  of  this  time  cool  the  solution,  make  up  to  8  c.c.  with  a 
saturated  solution  of  picric  acid,  and  then  add  0.4  c.c.  of  a  10% 
sodium  hydroxide  solution.  At  this  point  it  is  also  well  to  empha- 
size the  fact  that  the  unknown  and  the  standard  must  be  made  up 
at  the  same  time.  To  20  c.c.  of  standard  creatinine,1  add  1  c.c.  of  a 
10%  solution  of  sodium  hydroxide  (this  should  be  added  at  the 
same  time  the  0.4  c.c.  is  added  to  the  unknown)  and  then  compare 
the  unknown  and  the  standard  after  standing  for  ten  minutes. 
The  formula  for  computation  of  this  result  is  as  follows :  89  minus 
reading  x  0.0179  x  20  =  mgms.  creatinine  and  creatine. 

Slightly  less  accurate  results  may  be  obtained  by  using  N/4  po- 
tassium bichromate2  as  a  standard. 

If  the  accurate  value  of  creatine  is  desired,  this  is  obtained  by 
subtracting  the  value  of  creatinine  from  the  creatine  and  creatinine 
and  multiplying  it  by  1.16. 

Example. — Let  us  assume  that  the  reading  was  69.  Then  89 
minus  69  =  20  x  0.0179  =  0.358  x  20  =  7.16  mgms.  of  creatinine  +  cre- 
atine =  7.16  -  2.2375  (mgms.  creatinine)  =4.9225x1.16  =  5.7101 
mgms.  creatine  per  100  c.c.  blood  (normal). 

JThis  standard  is  made  by  dissolving  IS  mgms.  of  pure  creatinine  and  making  up  to 
one  liter  with  saturated  picric  acid. 

2This  is  prepared  by  dissolving  12.28  grams  of  potassium  bichromate  in  distilled  water 
and  making  up  to  1000  c.c. 


36 


CHAPTER  V. 
URIC  ACID. 

Place  10  c.c.  of  blood  in  a  casserole  (Fig.  12)  of  at  least  375 
c.c.  capacity.  Add  50  c.c.  of  N/100  acetic  acid. 

The  N/100  acetic  acid  is  prepared  by  adding  0.6  c.c.  glacial 
acid  to  1  liter  of  distilled  water. 

This  lasts  about  two  weeks  and  should  be  cast  aside  after  that 
time  and  a  new  solution  made. 

Place  the  casserole  in  a  water-bath  and  heat  until  coagulation 
takes  place.  This  usually  takes  about  ten  minutes  with  an  cffi- 


Fig.  12. — Casserole. 

cient  water-bath.  Heat  the  casserole  over  a  free  flame  until  it 
comes  to  a  boil,  stirring  continuously.  Now  add  about  one  spoon- 
ful (4  c.c.)  of  alumina  cream.  (For  the  preparation  of  alumina 
cream,  take  500  c.c.  of  8%  aluminum  acetate  in  acetic  acid.  This 
8%  solution  may  be  purchased  from  any  reliable  chemical  house. 
Precipitate  this  with  sodium  bicarbonate  (dry)  until  the  solution 
is  neutral.  This  is  verified  by  litmus  paper  estimation.  Allow 
this  to  stand  24  hours  and  decant  the  supernatant  fluid.  This  is 
repeated  six  times,  that  is,  add  distilled  water  and  mix  and  allow 
to  stand  another  24  hours.  In  this  way,  it  takes  about  six  days 
to  make  this  reagent.  On  the  last  day  the  precipitate  is  filtered 
and  put  in  a  jar,  with  the  addition  of  5  c.c.  of  chloroform.  It  is 
now  ready  for  use.  It  should  be  kept  in  the  ice  box  for  storage.) 
Boil  for  one  minute,  stirring  continuously.  We  now  filter  this 
solution  and  wash  back  the  coagulum  on  the  filter  paper  into 

37 


38 


BLOOD    AND    URINE    CHEMISTRY 


the  casserole  with  about  100  c.c.  of  hot  distilled  water.  Heat  this 
mixture  in  the  casserole  over  a  free  flame  to  the  boiling  point,  and 
filter.  Evaporate  the  combined  filtrates  down  to  1  or  2  c.c.  in  the 
following  manner.  Boil  slowly  over  a  free  flame  until  the  volume 
has  been  reduced  to  about  50  c.c.  Continue  the  evaporation  in  the 
water-lath  down  to  1  or  2  c.c.  Transfer  this  to  a  conical  centri- 
fuge tube  of  15  c.c.  capacity,  washing  the  casserole  with  two  or  three 
hot  water  portions.  The  final  volume  in  the  centrifuge  tube  should 
be  kept  below  10  c.c.  When  this  has  cooled,  add  fifteen  drops  of 
ammoniacal-silver-magnesium1  mixture  and  the  tube  is  shaken  and 
placed  in  a  refrigerator  for  about  fifteen  minutes  (to  allow  for 


Fig.    13. — Showing  centrifuge   tube   attached   to   suction. 

the  precipitation  of  purine).  Centrifuge  the  tube  from  three  to 
five  minutes,  then  invert,  and  pour  off  the  supernatant  fluid. 
Wipe  the  lip  of  the  tube  with  filter  paper  and  allow  the  ammonia 
to  volatilize  by  suction.  This  is  accomplished  by  attaching  the  cen- 
trifuge tube  to  the  rubber  tubing  of  the  Chapman  pump  (Fig.  13). 
We  are  now  ready  for  the  development  of  color  and  the  read- 
ing. As  before  mentioned,  the  beginner  should  work  as  fast  as 
possible  as  the  color  may  fade  or  turbidity  may  develop.  It  is  a 
general  axiom,  of  course,  that  turbid  solutions  cannot  very  well 
be  read  in  a  colorimeter. 


URIC   ACID 


39 


Prepare  a  100  c.c.  graduated  cylinder  for  the  unknown  and  a 
50  c.c.  volumetric  flask  for  the  standard  solution  (Fig.  14).  Then 
pipette  5  c.c.  of  uric  acid  standard2  (5  c.c.=l  mgm.  of  uric  acid) 
into  the  50  c.c.  volumetric  flask.  To  the  uric  acid  standard  add  two 
drops  of  a  5%  solution  of  potassium  cyanide,  2  c.c.  of  Folin-Macal- 
lum3  reagent,  20  c.c.  of  saturated  sodium  carbonate,  and  in  one 
minute  add  water  to  the  50  c.c.  mark.  (See  Plate  I  for  the  color 
of  the  standard  uric  acid  wedge.)  To  the  precipitate  in  the  centri- 
fuge tube  add  2  drops  of  a  5%  potassium  cyanide  solution  (the  tube 


Fig.   14. — Volumetric  flask. 

is  shaken  so  as  to  dissolve  the  precipitate),  and  2  c.c.  of  the  Folin- 
Macallum  reagent,  and  then  wash  the  contents  of  the  centrifuge 
tube  into  a  100  c.c.  graduate  with  from  15  to  20  c.c.  of  saturated 
sodium  carbonate.  If  the  color  is  developed  well,  use  more  car- 
bonate, i.  e.,  20  c.c.  when  the  color  is  stronger  than  the  standard, 


4"0 


BLOOD   AND    URINE    CHEMISTRY 


and  15  c.c.  when  it  is  weaker.  The  fundamental  principle  of  these 
dilutions  in  microchemical  work  is  to  have  the  unknown  solution 
weaker  in  color  than  the  standard  solution.  A  period  of  time  of 
from  forty  to  sixty  seconds  should  be  allowed  to  elapse  before  de- 
termining whether  to  dilute  to  50  or  100  c.c.  Dilate  with  dis- 
tilled water  to  25,  50,  or  100  c.c.,  depending  upon  the  depth  of 
color  obtained.  Table  III  gives  the  data  for  working  out  the 
amount  of  uric  acid  present. 

Example. — Suppose  the  final  dilution  of  the  unknown  was  25 
and  the  reading  was  42.  42  in  the  table  is  equivalent  to  1.24 
mgms.  This  is  divided  by  4  because  it  is  !/4  as  strong  as  the 
amount  in  the  table  (i.e.,  i/4  of  100)  which  equals  0.31  mgms.  in 
10  c.c.  of  blood  (which  is  the  amount  of  blood  we  started  with). 
In  100  c.c.  of  blood  we  would  have  10  x  0.31=3.1  mgms. 


TABLE  III4 


ESTIMATION  OF  URIC  ACID  WITH  HELLIGE  COLORIMETER 


COLORI- 

URIC  ACID 

COLORI- 

URIC  ACID 

COLORI- 

URIC  ACID 

METRIC 

MGMS.  PER 

METRIC 

MGMS.  PER 

METRIC 

MGMS.  PER 

READING 

DILUTION 

READING 

DILUTION 

READING 

DILUTION 

OF    100   C.C. 

OF    100    C.C. 

OF  100  C.C. 

20 

1.67 

40 

1.28 

60 

0.88 

21 

1.65 

41 

1.26 

61 

0.86 

22 

1.63 

42 

1.24 

62 

0.84 

23 

1.61 

43 

1.22 

63 

0.82 

24 

1.59 

44 

1.20 

64 

0.81 

25 

1.57 

45 

1.18 

65 

0.79 

26 

1.55 

46 

1.16 

66 

0.77 

27 

1.53 

47 

1.14 

67 

0.75 

28 

1.51 

48 

1.12 

68 

0.73 

29 

1.49 

49 

1.10 

69 

0.71 

30 

1.48 

50 

1.08 

70 

0.69 

31 

1.46 

51 

1.06 

71 

0.67 

32 

1.44 

52 

1.04 

72 

0.65 

33 

1.42 

53 

1.02 

73 

0.63 

34 

1.40 

54 

1.00 

74 

0.61 

35 

1.38 

55 

0.98 

75 

0.59 

36 

1.36 

56 

0.96 

76 

0.57 

37 

1.34 

57 

0.94 

77 

0.55 

38 

1.32 

58 

0.92 

78 

0.53 

39 

1.30 

59 

0.90 

79 

0.51 

•Myers   and   Fine:      Chemical    Composition    of   the   Blood   in   Health   and    Disease,    New 
York,   1915. 


URIC   ACID  41 

BIBLIOGRAPHY. 

Benedict  and  Hitchcock:     Jour.  Biol.  Chem.,  1915,  vol.  xx,  pp.  619,  629,  and 

633. 

Chace  and  Myers:     Jour.  Am.  Med.  Assn.,  1916,  vol.  Ixvii,  pp.  931,  932. 
Fine  and  Chace:     Jour.  Pharm.  and  Exper.  Therap.,  1914,  vol.  vi,  p.  219. 
Folin  and  Denis:     Arch.  Int.  Med.,  1915,  vol.  xvi,  p.  33;  Jour.  Biol.  Chem., 

1912,  vol.  xiii,  p.  469;   Ibid.,  1913,  vol.  xiv,  pp.  29  and  95. 
Folin  and  Macallum :     Jour.  Biol.  Chem.,  1912,  vol.  xiii,  p.  363. 
Myers  and  Fine:     "Blood  in  Health  and  Disease,"  1915,  p.  14. 
Weiss:     New  York  Med.  Jour.,  1914,  vol.  c,  p.  180. 


CHAPTER  VI. 
UREA. 

Into  a  test  tube  that  will  readily  slip  into  a  100  c.c.  graduated 
cylinder  introduce  2  c.c.  of  distilled  water  and  0.1  gm.  of  urease,1 
and  2  c.c.  of  blood  with  an  Ostwald  pipette;  then  incubate 
the  tube  in  a  beaker  of  water  at  50°  C.  for  one-half  hour.  At  the 
end  of  this  time  add  two  drops  of  caprylic  alcohol  or  1  c.c.  of 
amylic  alcohol  to  prevent  foaming  in  aeration. 

We  now  direct  our  attention  to  the  manner  of  setting  up  the 
glassware  for  the  continuation  of  this  test.  The  chemistry  of 
this  estimation  is  about  as  follows:  The  enzyme  urease  converts 
urea  into  ammonium  carbonate.  The  ammonia  is  then  liberated 
by  aeration  in  the  presence  of  sodium  carbonate  in  excess  and 
goes  over  into  the  hydrochloric  acid  as  ammonium  chloride.  This 
can  be  determined  colorimetrically  by  the  use  of  Nessler's  reagent. 
There  should  be  two  cylinders  for  each  sample  of  blood.  If  more 
than  one  specimen  of  blood  is  to  be  examined,  these  cylinders  may 
be  run  in  series,  two  for  each  test.  One  cylinder  is  graduated,  the 
other  nongraduated.  Fig.  15  shows  the  manner  of  arranging  this 
glassware. 

-  A  two-hole  rubber  stopper  is  placed  in  each  cylinder.  Cylinder 
1  (A- A')  is  graduated  and  is  connected  with  the  suction.  Cyl- 
inder 2  (B-B'}  is  nongraduated  and  is  connected  with  the  acid 
wash  (C)  bottle.  This  acid  wash  bottle  is  simply  a  bottle  con- 
taining sulphuric  acid  (10%)  placed  at  the  end  of  the  outfit  to  pre- 
vent the  ammonia  in  the  air  from  gaining  entrance  into  the  test. 
Cylinder  1  (A- A'}  has  a  short  tube  bent  at  right  angles  connected 
to  the  suction  and  only  extending  in  the  cylinder  to  a  point  just 
within  the  cylinder.  This  is  tube  F-F'.  Tube  G-G'  extends  almost 
to  the  bottom  of  cylinder  ].  It  has  a  sealed  ending  with  small  holes 
punched  in  its  side.  This  can  readily  be  done  as  follows:  The 
holes  may  be  made  with  a  platinum  wire  which  is  at  white  heat, 
provided  the  glass  is  only  moderately  hot.  Cylinder  2  has  a  right- 

'Urease  may  be  purchased  from  the  Arlington   Chemical   Co.,   Yonkers,  N.   Y. 

42 


UREA 


43 


44  BLOOD    AND    URINE    CHEMISTRY 

angle  tube  extending  to  a  point  just  below  the  stopper  (D).  It 
has  another  tube  with  a  straight  open  end  dipping  into  the  test 
tube  (E)  and  running  out  to  be  connected  either  with  the  acid 
wash  bottle  extension  or  with  another  series  of  cylinders  in  case 
more  than  one  specimen  of  blood  is  under  examination. 

Into  the  100  c.c.  graduated  cylinder  (cylinder  1)  place  20  c.c. 
distilled  water  and  two  to  three  drops  of  10%  hydrochloric  acid. 
Now  close  cylinder  1  and  open  cylinder  2.  To  the  test  tube  con- 
taining the  digested  blood  allow  an  equal  volume  of  saturated 
sodium  carbonate  to  slowly  run  down  under  the  blood.  Immedi- 
ately and  carefully  insert  the  tube  into  cylinder  2  and  immediately 
close,  and  then  carefully  and  tightly  seal  the  connection.  The  suc- 
tion is  started  by  means  of  the  Chapman  pump,  the  rate  is  slow 
for  about  five  minutes  and  then  gradually  increased  as  much  as 
the  apparatus  will  stand.  The  aeration  is  kept  up  from  thirty  to 
forty-five  minutes.  At  the  end  of  this  time,  disconnect  the  tube 
and  use  cylinder  1  for  the  final  determination.  Remove  the  rubber 
stopper  from  cylinder  1  and  wash  the  tube  with  distilled  water  (2 
to  3  c.c.). 

We  now  come  to  the  development  of  color.  Into  a  50  c.c.  volu- 
metric flask  pipette  5  c.c.  of  ammonium  sulphate  solution  contain- 
ing 1  mgm.  of  nitrogen  (this  is  the  standard  solution),  add  25  c.c. 
distilled  water,  and  then  20  c.c.  Nesslcr's  solution,  diluted  1  to  5. 
(See  Plate  I  for  the  standard  color  of  1  mgm.  of  nitrogen.) 

The  standard  ammonium  sulphate  solution  is  prepared  as 
follows : 

Dissolve  0.944  gm.  ammonium  sulphate-  of  the  highest 
purity  in  distilled  water  and  make  up  to  1000  c.c.  in  a  volu- 
metric flask. 

Nesslcr's  solution  is  prepared  as  follows:  for  one  liter  we  need: 

Mercuric  iodide  100  gms. 

Potassium  iodide  50  gms. 

Potassium   hydroxide  200  gms. 

Place  the  mercuric  iodide  and  the  potassium  iodide,  both 
finely  powdered,  into  a  liter  volumetric  flask  and  add  about 
400  c.c.  distilled  water.  Now  dissolve  the  potassium 
hydroxide  in  500  c.c.  distilled  water,  cool  thoroughly,  and 
add  with  constant  shaking  to  the  mixture  in  the  flask.  The;i 
make  up  to  one  liter  with  water.  This  usually  becomes  per- 
fectly clear.  Keep  at  37°  C.  in  incubator  over  night  or  until 


UREA 


45 


the  yellowish  white  precipitate  which  may  settle  out  is 
thoroughly  dissolved  and  only  a  small  amount  of  dark 
brownish  red  precipitate  remains.  The  solution  is  now 
ready  to  be  siphoned  off  and  used. 

To  cylinder  1  containing  the  unknown  in  the  form  of  ammonium 
chloride,  add  from  10  to  20  c.c.  of  diluted  Nessler's  solution  (1  to 
5),  dependent  upon  the  depth  of  color,  and  then  dilute  to  50  c.c., 
100  c.c.,  etc.,  depending  upon  the  color.  The  colorimetric  reading 
should  be  made  at  once  and  computed  from  the  following  table : 


TABLE  IV2 


ESTIMATION  OF  NITROGEN  WITH  THE  HELLIGE  COLORIMETER 


COLORI- 

NITROGEN 

COLORI- 

NITROGEN 

COLORI- 

NITROGEN- 

METRIC 

MGMS.  PER 

METRIC 

MGMS.  PER 

METRIC 

MOMS.  PER 

READING 

DILUTION 

READING 

DILUTION 

READING 

DILUTION 

OF    100   C.C. 

OF    100   C.C. 

OF  100  C.C. 

20 

1.73 

40 

.31 

60 

0.89 

21 

1.71 

41 

.29 

61 

0.87 

22 

1.69 

42 

.27 

62 

0.85 

23 

1.67 

43 

.25 

63 

0.83 

24 

.65 

44 

.23 

64 

0.81 

25 

.62 

45 

.20 

65 

0.78 

26 

.60 

46 

.18 

66 

0.76 

27 

.58 

47 

.16 

67 

0.74 

28 

.56 

48 

.14 

68 

0.72 

29 

.54 

49 

.12 

69 

0.70 

30 

1.52 

50 

1.10 

70 

0.67 

31 

1.50 

51 

1.08 

7 

0.65 

32 

1.48 

52 

1.06 

72 

0.63 

33 

1.46 

53 

1.04 

73 

0.61 

34 

1.44 

54 

1.02 

74 

0.59 

35 

1.41 

55 

0.99 

75 

0.56 

36 

1.39 

56 

0.97 

76 

0.54 

37 

1.37 

57 

0.95 

77 

0.52 

38 

1.35 

58 

0.93 

78 

0.50 

39 

1.33 

59 

0.91 

79 

0.48 

2Myers  and  Fine:  Chemical  Composition  of  the  Blood  in  Health  and  Disease,  New 
York,  1915. 

Example. — Suppose  the  dilution  was  to  50  and  our  reading  75. 
75  on  our  scale  is  equivalent  to  0.56  mgms.  Divide  this  by  2  be- 
cause our  dilution  was  to  50,  which  is  one-half  of  100,  which  will 
give  us  0.28  mgms.  in  2  c.c.  of  blood.  In  1  c.c.  of  blood  we  would 


46  BLOOD   AND   URINE    CHEMISTRY 

have  0.14  mgms.  of  urea  nitrogen  and  in  100  c.c.  of  blood  we  would 
have  14  mgms.,  which  is  about  normal. 

Should  it  be  desired  to  convert  this  urea  nitrogen  into  urea,  the 
results  are  always  multiplied  by  the  factor  2.14. 

BIBLIOGRAPHY. 

Chace  and  Myers:     Jour.  Am.  Med.  Assn.,  1916,  vol.  Ixvii,  pp.  931,  932. 
Combe  and  Levi:     Rev.  mod.  de  la  Suissc  romande.,  1915,  vol.  xxxv,  p.  413. 
Folin  and  Denis:     Jour.  Biol.  Chem.,  1916,  vol.  xxvi,  p.  505;  Ibid.,  1912,  vol. 

xi,  p.   527. 

Folin  and  Pettibone:     Jour.  Biol.  Chem.,  1912,  vol.  xi,  p.  507. 
Foster:    Jour.  Am.  Med.  Assn.,  1916,  vol.  Ixvii,  p.  927. 
Kristeller:     Ztschr.  f.  exper.  Path.  u.  Therap.,  1914,  vol.  xvi,  p.  496. 
Marshall:     Jour.  Biol.  Chem.,  1913,  vol.  xiv,  p.  283;  Ibid.,  1913,  vol.  xv,  pp. 

287  and  495. 

Neumann :     Biochem.  Ztschr.,  1915,  vol.  Ixix,  p.  134. 
Olivieri:     Riv.  osped.,  1914,  vol.  iv,  p.  221. 
Rose  and  Coleman:    Biochem.  Bull.,  1914,  vol.  iii,  p.  411. 
Siebeck:    Deutseh.  Arch.  f.  klin.  Med.,  1914,  vol.  cxvi,  p.  58. 
Van  Slyke  and  Cullen:     Jour.  Am.  Med.  Assn.,  1914,  vol.  Ixii,  p.  1558;  Jour. 

Biol.  Chem.,  1914,  vol.  xix,  p.  211;  Ibid.,  1916,  vol.  xxiv,  p.  117. 


CHAPTER  VII. 
NONPROTEIN  NITROGEN. 

In  a  50  c.c.  volumetric  flask  with  about  35  c.c.  of  2.5%  trichlor- 
acetic  acid,  add  5  c.c.  of  blood,  and  make  the  volume  up  to  50  c.c. 
with  2.5%  trichloracetic  acid.  Shake  the  flask  vigorously,  and 
at  the  end  of  30  minutes  (or  as  soon  after  as  convenient)  filter 
the  solution  through  a  dry  filter.  To  the  filtrate  add  about  two 
grams  of  kaolin,  and  shake  the  solution  vigorously.  After  allow- 
ing the  mixture  to  stand  for  a  few  minutes  (5  to  10),  filter  again. 
The  filtrate  should  now  be  quite  colorless.  Pipette  10  c.c.  of  the 
filtrate  (the  equivalent  of  1  c.c.  of  blood)  into  a  test  tube  about 
200  mm.  long  and  of  a  sufficient  diameter  to  slip  into  a  100  c.c. 


Fig.  16. — Microburner. 

gradua-ted  cylinder  (no  lip).  Then  add  one-tenth  to  three-tenths 
of  a  gram  of  potassium  sulphate,  a  drop  of  10%  copper  sulphate, 
and  1  c.c.  of  concentrated  sulphuric  acid  in  the  order  named 
(these  reagents  should  be  of  the  highest  purity).  This  is  then 
boiled  over  a  microburner  (Fig.  16),  at  first  gently,  until  a  dark 
brown  color  appears. 

At  this  point  it  might  be  well  to  call  the  attention  of  the  reader 
to  a  modification  of  this  test1  which  will  serve  for  blood  as  well 
as  urine  estimations,  and  which  will  serve  to  shorten  this  test 
about  ten  minutes.  Allow  the  solution  to  cool  and  add  a  drop 
of  peroxide  of  hydrogen.  If  the  mixture  does  not  clear,  heat 
gently  over  the  microburner.  Repeat  this  process  once  more  if 
the  mixture  is  not  perfectly  clear  (digested).  One  drop  of  perox- 
ide of  hydrogen  will  usually  suffice.  Now  allow  the  tube  to  cool 
for  a  few  minutes  and  then  add  about  5  or  6  c.c.  of  distilled  water. 


Kiradwohl   and   Blaivas:     Jour.  Am.   Med.  Assn.,   Sept.   9,   1916,  vol.   Ixvii,  p. 

47 


48 


BLOOD    AND    URINE    CHEMISTRY 


As  a  means  of  removing  fumes,  the  suction  is  connected  by  a 
two-hole  stopper  to  a  large  bottle  containing  a  solution  of  sodium 
hydroxide  (Fig.  17).  The  short  tube  A,  bent  at  right  angles,  should 
be  connected  to  the  suction.  The  tube  B  should  be  attached  to  a 


Fig.   17. — Apparatus  for  removing  fumes  in  connection  with   nitrogen   determinations. 


NONPROTEIN    NITROGEN  49 

funnel  over  the  mouth  of  the  test  tube  D.  After  a  few  determi- 
nations have  been  made,  it  is  well  to  wash  the  funnel  to  remove 
any  acid  which  may  have  condensed  upon  it. 

Aeration  is  carried  out  exactly  in  the  manner  as  for  urea, 
only  that  saturated  sodium  hydroxide  is  used  instead  of  saturated 
sodium  carbonate.  The  same  table2  is  also  used  for  calculation 
and  the  results  obtained  for  1  c.c.  of  blood.* 

BIBLIOGRAPHY. 

Agnew:     Arch.  Int.  Med.,  1914,  vol.  xiii,  p.  485. 
Austin  and  Miller:     Jour.  Am.  Med.  Assn.,  1914,  vol.  Ixiii,  p.  944. 
Bock  and  Benedict:     Jour.  Biol.  Chem.,  1915,  vol.  xx,  p.  47. 
Farr  and  Austin:     Jour.  Exper.  Med.,  1913,  vol.  xviii,  p.  228. 
Farrtind  Krumbhaar:     Jour.  Am.  Med.  Assn.,  1914,  vol.  Ixiii,  p.  2214. 
Farr  and  Williams:     Am.  Jour.  Obst.,  1914,  vol.  Ixx,  p.  614;  Am.  Jour.  Med. 

Sc.,  1914,  vol.  cxlvii,  p.  556. 
Fitz:      Arch.  Int.  Med.,  1915,  vol.  xv,  p.  524. 
Folin:     Jour.  Biol.  Chem.,  1915,  vol.  xxi,  p.   195. 
Folin  and  Denis:      Jour.   Biol.  Chem.,   1912,  vol.  xi,  pp.   87,   161,  503,  527; 

Ibid.,  1912,  vol.  xii,  p.  141,  253 ;  Ibid.,  1913,  vol.  xiv,  p.  29 ;  Ibid.,  1913, 

vol.  xvii,  p.  487,  493;    Ibid.,   1915,  vol.  xxii,  p.   321;    Ibid.,   1916,  vol. 

xxvi,  p.  491. 

Folin,  Denis  and  Seymour:     Arch.  Int.  Med.,  1914,  vol.  xiii,  p.  224. 
Folin  and  Farmer:     Jour.  Biol.  Chem.,  1912,  vol.  xi,  p.  493. 
Folin  and  Lyman :     Jour.  Biol.  Chem.,  1912,  vol.  xii,  p.  259. 
Foster:     Arch.  Int.  Med.,  1915,  vol.  xv,  p.  356;  Jour.  Am.  Med.  Assn.,  1916, 

vol.  Ixvii,  p.  927. 

Frothingham :     Am.  Jour.  Med.  Sc.,  1915,  vol.  cxlix,  p.  808. 
Frothingham  and  Smillie:     Arch.  Int.  Med.,  1914,  vol.  xiv,  p.  541. 
Gradwohl  and  Blaivas :     Jour.  Am.  Med.  Assn.,  Sept.  9,  1916,  vol.  Ixvii,  p.  809. 
Greenwald:     Jour.  Biol.  Chem.,  1915,  vol.  xxi,  p.  61. 
Gulick:     Jour.  Biol.  Chem.,  1914,  vol.  xviii,  p.  541. 
Harding  and  Wareneford:     Jour.  Biol.  Chem.,  1915,  vol.  xxi,  p.  69. 
Hertz:     Wien.  klin.  Wchnschr.,  1914,  vol.  xxvii,  p.  323. 
Hohlweg:     Med.  Klin.,  1915,  vol.  xi,  p.  331;  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u. 

Chir.,  1915,  vol.  xxviii,  p.  459. 

Hopkins  and  Jones:     Arch.  Int.  Med.,  1915,  vol.  xv,  p.  964. 
Karsner  and  Denis:     Jour.  Exper.  Med.,  1914,  vol.  xix,  p.  259. 
Lowy:     Ztschr.  f.  physiol.   Chem.,   1912,  vol.  Ixxix,  p.   349. 
McLean  and  Selling:     Jour.  Biol.  Chem.,  1914,  vol.  xix,  p.  31. 
Michand:     Cor.-Bl.  f.  schweiz.  Aerzte,  1913,  vol.  xliii,  p.  1474. 
Mosenthal :    Arch.  Int.  Med.,  1914,  vol.  xiv,  p.  844. 
Myers  and  Fine:     Jour.  Biol.  Chem.,  1915,  vol.  xx,  p.  391. 
Pepper  and  Austin:    Jour.  Biol.  Chem.,  1915,  vol.  xxii,  p.  81. 
Plass:     Am.  Jour.  Obst.,  1915,  vol.  Ixxi,  p.  608. 
Pribram:     Zentralbl.  f.  inn.  Med.,  1914,  vol.  xxxv,  p.  153. 
Schlutz  and  Pettibone :     Am.  Jour.  Dis.  Child.,  1915,  vol.  x,  p.  206. 
Taylor  and  Hutton :     Jour.  Biol.  Chem.,  1915,  vol.  xxii,  p.  63. 
Taylor  and  Lewis:     Jour.  Biol.  Chem.,  1915,  vol.  xxii,  p.   71. 
Tileston  and  Comfort:      Arch.  Int.  Med.,  1914,  vol.  xiv,  p.  620;   Am.  Jour. 

Dis.  Child.,  1915,  vol.  x.  p.  278. 
Woods:     Arch.  Int.  Med.,  1915,  vol.  xvi,  p.  577. 

!See  Table  IV,  p.  45. 

*See  Appendix  at  end  of  the  book  for  a  description  of  Folin's  new  method  for  the 

estimation  of  nonprotein  nitrogen,  using  the  Bock-Benedict  or  Duboscq  colorimeter.  It 
gives  better  results  than  any  other  method.  ., 


CHAPTER  VIII. 
CHOLESTEROL.1 

Preparation  of  Sample. — Run  2  c.c.  of  whole  blood,  plasma,  or 
scrum  slowly  (a  slow  stream  of  drops)  from  a  pipette  into  about 
75  c.c.  of  a  mixture  of  redistilled  alcohol  and  ether  (3  parts  al- 
cohol, 1  part  ether)  in  a  100  c.c.  graduated  flask.  Keep  the  con- 
tents of  the  flask  in  motion  during  the  process  so  that  there  is 
no  clumping  of  the  precipitated  material.  Raise  contents  of  the 
flask  to  boiling  by  immersion  in  a  water-bath  (with  constant  shak- 
ing to  avoid  superheating),  cool  to  room  temperature,  fill  to  the 
mark  with  alcohol-ether,  mix  and  filter.  The  filtered  liquid  if 
placed  in  a  tightly  stoppered  bottle  in  the  dark  will  keep  un- 
changed for  a  considerable  time  so  that,  if  it  is  not  convenient 
to  complete  the  determination  at  once,  the  sample  may  be  carried 
to  the  above  stage  and  left  to  a  more  suitable  time. 

By  running  the  blood  slowly  into  the  large  quantity  of  alcohol- 
ether,  as  above,  the  protein  material  is  precipitated  in  finely  di- 
vided form  and  under  these  conditions  the  short  heating  combined 
with  the  great  excess  of  solvent  is  adequate  for  complete  extrac- 
tion of  serum  or  plasma.  The  extraction,  while  not  so  complete 
in  the  case  of  whole  blood,  is  believed  to  be  better,  because  of  the 
higher  values  obtained  than  that  obtained  by  any  other  method  in 
use  at  the  present  time. 

Determination. — Measure  10  c.c.  of  the  alcohol-ether  extract  in- 
to a  small  flat-bottomed  beaker  and  evaporate  just  to  dryness  over 
a  water-bath  or  electric  stove.  Any  heating,  after  dryness  is 
reached,  produces  a  brownish  color  which  passes  into  the  chloro- 
form and  renders  the  subsequent  determination  difficult  or  im- 
possible. The  cholesterol  is  extracted2  from  the  dry  residue  by 
boiling  out  three  or  four  times  with  successive  small  portions  of 
chloroform  and  decanting  into  a  10  c.c.  glass  stoppered,  gradu- 

M'.loor:     Jour.   Riol.   Chem.,   1916,  vol.   xxiv,  p.  229. 

2In  order  to  get  an  adequate  extraction  with  the  small  amounts  of  chloroform  used, 
pn  excess  (3  c.c.)  should  be  added  each  time  and  the  mixture  allowed  to  boil  down  to 
half  its  volume  or  less,  before  decanting. 

50 


CHOLESTEROL 


51 


ated  cylinder.  The  combined  extracts  after  cooling  (5  c.c.  or  less) 
are  then  made  up  to  5  c.c.  The  solution  should  be  colorless  but 
not  necessarily  clear,  since  the  slight  turbidity  clears  up  on  adding 
the  reagents. 

To  this  solution  add  2  c.c.  of  acetic  anhydride  and  0.1  c.c.  of 
concentrated  sulphuric  acid  and  after  mixing  place  in  the  dark 

TABLE  V3 
ESTIMATION  OF  CHOLESTEROL  WITH  THE  HELLIGE  COLORIMETER 


COLORI- 

CHOLESTEROL 

COLORI- 

CHOLESTEROL 

COLORI- 

CHOLESTEROL 

METRIC 

MOMS. 

METRIC 

MGMS. 

METRIC 

MGMS. 

READING 

DILUTION 

READING 

DILUTION 

READING 

DILUTION 

OF  5  C.C. 

OF  5  C.C. 

OF  5  C.C. 

15 

0.74 

35 

0.57 

55 

0.40 

16 

0.73 

36 

0.56 

56 

0.40 

17 

0.72 

37 

0.55 

57 

0.39 

18 

0.71 

38 

0.55 

58 

0.38 

19 

0.70 

39 

0.54 

59 

0.37 

20 

0.69 

40 

0.53 

60 

0.36 

21 

0.69 

41 

0.52 

61 

0.35 

22 

0.68 

42 

0.51 

62 

0.35 

23 

0.67 

43 

0.5> 

63 

0.34 

24 

0.66 

44 

0.50 

64 

0.33 

25 

0.65 

45 

0.49 

65 

0.32 

26 

0.65 

46 

0.48 

66 

0.31 

27 

0.64 

47 

0.47 

67 

0.30 

28 

0.63 

48 

0.46 

68 

0.30 

29 

0.62 

49 

0.45 

69 

0.29 

30 

0.61 

50 

0.45 

70 

0.28 

31 

0.60 

51 

0.44 

71 

0.27 

32 

0.59 

52 

0.43 

72 

0.26 

33 

0.59 

53 

0.42 

73 

0.25 

34 

0.58 

54 

0.41 

74 

0.24 

'This  table  is  good  for  both  standards  given  above  (cholesterol  and  Naphthol  Green 
11).  Myers  and  Fine:  Chemical  Composition  of  the  Blood  in  Health  and  Disease,  New 
York,  1915. 

for  10  minutes  to  allow  for  the  development  of  the  color.  Then 
compare  in  the  colorimeter  (Hellige)  with  a  standard  choles- 
terol solution  upon  which  the  color  is  developed  in  the  same  way.4 
See  Plate  I  for  the  standard  color  of  cholesterol. 


*For  the  preparation  of  standard  with  pure  cholesterol,  pipette  2  c.c.  of  an  0.08% 
freshly  prepared  chloroform  solution  of  cholesterol  into  a  dry,  accurately  graduated 
25  c.c.  cylinder  and  make  up  to  10  c.c.  with  chloroform  and  add  4  c.c.  acetic  anhydride 
and  0.2  c.c.  of  concentrated  sulphuric  acid.  Care  should  be  taken  that  the  unknown 
and  the  standard  are  made  together  and  both  the  colors  should  be  allowed  to  develop 
at  the  same  time.  The  reason  for  this  is  that  the  colors  fade  rather  rapidly.  It  is 
very  important  that  the  wedge  and  the  cup  of  the  colorimeter  be  perfectly  dry. 


52  BLOOD    AND   URINE    CHEMISTRY 

An  aqueous  solution  of  Naphthol  Green  B5  can  also  be  used  as 
a  standard.  The  cholesterol  in  0.2  c.c.  of  blood,  serum,  or  plasma, 
can  be  obtained  from  Table  V.  This  table  is  suitable  for  both  stand- 
ards (pure  cholesterol  or  Naphthol  Green  B). 

The  result  multiplied  by  500  will  give  the  percentage  of  choles- 
terol. 

Example. — Reading  is  60  which  equals  0.36  mgms.  cholesterol 
in  0.2  c.c.  blood,  plasma,  or  serum.  0.36  x  500=180  mgms.  or  0.18%. 

BIBLIOGRAPHY. 

Autenrieth  and  Funk:     Miinchen.  med.  Wchnschr.,  1913,  vol.  Ix,  p.  1243. 

Bang:     Chemie  und  Biochemie  der  Lipoide,  Wiesbaden,  1911,  pp.   20-27. 

Bloor:     Jour.  Biol.  Chem.,  1915,  vol.  xxiii,  p.  317;  Ibid.,  1916,  vol.  xxiv,  p.  227. 

Frank:      Jour.  Biol.  Chem.,  1916,  vol.  xxiv,  p.  431. 

Grigaut:     Compt.  rend.  Soc.  de  biol.,  1911,  vol.  Ixxi,  p.  531. 

Hanes:     Bull.  Johns  Hopkins  Hosp.,  1912,  vol.  xiii,  p.  77. 

Henes:     New  York  State  Jour.  Med.,  1915,  vol.  xv,  p.  310;  Jour.  Am.  Med. 

Assn.,   1914,  vol.  Ixiii,   p.   146. 
Lifschiitz:      Ztschr.  f.  physiol.  Chem.,  1907,  vol.   i,  p.  437;   Ibid.,   1907,  vol. 

liii,  p.  140;  Ibid.,  1908,  vol.  Iviii,  p.  175;  Ibid.,  1909,  Ixiii,  p.  223;  Ibid., 

1914,  vol.   xci,   p.   309;    Ibid.,   1914,   vol.   xcii,  p.   383;    Ibid.,   1914,   vol. 

xciii,  p.  209;  Biochem.  Ztschr.,  1913,  vol.  Hi,  p.  206. 
Myers  and  Gorham:     Post-Graduate  Med.  Jour.,  1914,  vol.  xxix,  p.  938. 
Schmidt:     Arch.  Int.  Med.,  1914,  vol.  xii,  p.  123. 
Weston:     Jour.  Med.  Research,  1912,  vol.  xxvi,  p.  47. 
Weston  and  Kent:     Jour.  Med.  Research,  1912,  vol.  xxvi,  p.  531. 
Windaus :    Ztschr.  f .  physiol.  Chem.,  1910,  vol.  Ixv,  p.  110. 

5For  the  preparation  of  Naphthol  Green  B,  dilute  2  c.c.  of  a  0.1%  aqueous  solu- 
tion of  the  dye  to  17  c.c.  with  distilled  water.  The  diluted  solution  appears  to  keep 
for  a  little  time,  while  the  concentrated  solution  apparently  will  keep  for  a  considerable 
time.  The  permanency  of  the  solution  and  the  fact  that  the  color  is  practically  iden- 
tical with  that  obtained  from  cholesterol  makes  the  standard  very  convenient.  Myers 
and  Fine  have  found  this  solution  nearly  identical  with  the  pure  cholesterol  standard. 
They  advise,  however,  that  in  preparing  a  new  solution  it  is  best  to  standardize  it  by 
plotting  a  new  curve. 


CHAPTER  IX. 
TOTAL  SOLIDS. 

For  the  determination  of  total  solids,  a  weighing  bottle  with  a 
glass  stopper  and  a  glass  loop  (Fig.  18),  which  goes  inside  of 
the  bottle  when  stoppered,  to  which  a  block  of  filter  paper  is  fas- 
tened, is  required.1  From  an  accurately  graduated  pipette,  allow 
0.3-0.6  gnis.  of  blood  to  flow  rapidly  on  the  filter  paper.  Quickly 
insert  the  stopper  to  prevent  any  loss  of  moisture,  weigh  the 
bottle.  Tilt  the  stopper,  and  'then  place  the  bottle  in  a  drying 


Fig.    18. — Weighing  bottle   for   total   solids. 

oven  at  105°  C.  overnight.  Whenever  convenient,  the  bottle  is 
cooled  in  the  desiccator  (care  being  taken  that  the  stopper  is 
closed)  and  again  weighed.  From  the  loss  of  moisture  the  total 
solids  may  be  calculated. 

Calculation. — Divide  the  weight  of  the  residue  by  the  weight 
of  the  blood  used.  The  quotient  is  the  percentage  of  solids  con- 
tained in  the  blood  examined. 


1Myers   and   Fine:      Chemical    Composition   of   the    Blood   in   Health   and   Disease    New 
York,  1915. 


CHAPTER  X. 

TOTAL  NITROGEN. 

Place  exactly  1  c.c.  of  blood  in  a  long-necked  Jena  glass  Kjcl- 
dahl  flask  (Fig.  19),  add  20  c.c.  of  concentrated  sulphuric  acid  and 
;>bout  0.2  grams  of  copper  sulphate,  and  boil  the  mixture  in  the 


Fig.   19.— Kjeldahl  flask. 

digestion  rack  (Fig.  20)  for  some  time  after  it  is  colorless  (about 
one  hour).  Allow  the  flask  to  cool  and  dilute  the  contents  with 
about  200  c.c.  of  ammonia-free  water.  Add  a  little  more  of  a 
saturated  sodium  hydroxide  solution  than  is  necessary  to  neutral- 
ize the  sulphuric  acid  (about  40  c.c.).  Introduce  into  the  flask 
a  little  coarse  pumice  stone  or  a  few  pieces  of  granulated  zinc 

54 


TOTAL   NITROGEN 


55 


to  prevent  bumping,  and  a  small  piece  of  paraffin  to  lessen  the 
tendency  to  froth.  By  means  of  a  safety  tube  connect  the  flask 
with  a  condenser  (Fig.  21)  so  arranged  that  the  delivery  tube 
passes  into  a  vessel  containing  a  known  volume  (the  volume  used 


Fig.   20. — Digestion  rack. 


depending  upon  the  nitrogen  contents  of  the  blood)  of  N/10  sul- 
phuric acid  to  which  has  been  added  a  few  drops  of  congo  red,1 
care  being  taken  that  the  end  of  the  delivery  tube  reaches  be- 
neath the  surface  of  the  fluid.  This  delivery  tube  should  be  of  a 


Fig.  21. — Kjeldahl  apparatus  showing  condenser. 

large  caliber  in  order  to  avoid  the  sucking  back  of  the  fluid.  Mix 
the  contents  of  the  distillation  flask  very  thoroughly  by  shaking 
(or  rotating)  and  distil  the  mixture  until  about  two-thirds  of  the 
solution  has  passed  over.  Titrate  the  partly  neutralized  N/10 

mixture  of  90   c.c.    of  distilled  water  and   10  c.c.   of  95% 


"0.5   gm.   of  congo   red   in 
alcohol. 


56  BLOOD   AND    URINE    CHEMISTRY 

sulphuric  acid  against  N/10  sodium  hydroxide.2  Calculate  the 
amount  of  nitrogen  in  1  c.c.  of  blood  and  multiply  by  100  to  re- 
port for  100  c.c.  of  blood. 

Calculation. — 1  c.c.  of  N/10  sulphuric  acid  is  the  equivalent  of 
0.0014  gm.  nitrogen.  (Preparation  of  N/10  NaOH  and  N/10 
H2S04.) 

Folin-Farmer  Microchemical  Method. 

Pipette  exactly  1  c.c.  of  the  blood  into  a  25  c.c.  volumetric  flask. 
Then  dilute  with  distilled  water  up  to  25  c.c.  Now  pipette  1  c.c. 
of  the  diluted  blood  into  a  test  tube  of  such  a  size  that  it  will  slip 
into  the  aeration  apparatus  (Fig.  15).  Add  one  to  three-tenths  of 
a  gram  of  potassium  sulphate,  a  drop  of  10%  copper  sulphate 
solution,  and  1  c.c.  of  concentrated  sulphuric  acid  in  the  order 
named,  and  carry  out  digestion  as  in  the  determination  of  non- 
protein  nitrogen.  (See  page  47.)  The  result  obtained  above  is 
for  1/25  c.c.  of  blood. 

BIBLIOGRAPHY. 

Dakin  and  Dudly:     Jour.  Biol.  Chem.,  1914,  vol.  xvii,  p.  275. 
Folin  and  Denis:     Jour.  Biol.  Chem.,  1916,  vol.  xxvi,  p.  473. 
Folin  and  Farmer:     Jour.  Biol.  Chem.,  1912,  vol.  xi,  p.  493. 
Gulick:     Jour.  Biol.  Chem.,  1914,  vol.  xviii,  p.  541. 

Myers  and   Fine:     Post-Graduate,   1914-15;    reprinted   as   "Chemical  Compo- 
sition of  the  Blood  in  Health  and  Disease,"  New  York,  1915. 

:For  the  preparation  of  N/10  sodium  hydroxide,  dissolve  4  gms.  of  sodium  hydroxide 
in  about  900  c.c.  of  distilled  water.  Titrate  this  against  a  decinormal  solution  of  oxalic 
acid  which  is  made  by  dissolving  exactly  6.285  gms.  of  pure  oxalic  acid  in  a  liter  of 
distilled  water.  The  decinormal  sodium  hydroxide  was  purposely  made  too  strong; 
therefore,  less  than  10  c.c.  of  the  alkali  will  be  required  to  neutralize  10  c.c.  of  the 
decinormal  oxalic  acid  solution.  Suppose  that  9.5  c.c.  of  the  alkali  only  were  required, 
then  every  remaining  portion  of  9.5  c.c.  of  the  unknown  would  have  to  be  diluted  with 
0.5  c.c.  of  distilled  water.  This  solution  will  contain  the  equivalent  of  one-tenth  of  its 
molecular  weight  in  grams  (4  grams)  in  1000  c.c.  of  distilled  water.  From  this  N/10 
alkali,  N/10  HC1  may  be  prepared. 


CHAPTER  XI. 


CHLORIDES.1 

Pipette  3  c.e.  of  blood  into  a  50  c.c.  graduated  centrifuge  tube 
(Fig.  22),  then  add  15  c.c.  of  N/100  acetic  acid  and  dilute  the 
volume  to  30  c.c.  with  distilled  water.  Place  the  tube  in  a  beaker 
of  boiling  water  to  bring  about  the  coagulation  of  the  protein, 
care  being  taken  that  the  contents  of  the  tube  are  agitated  oc- 
casionally with  a  stirring  rod.  After  the  protein  has  coagulated, 
the  tube  is  cooled,  again  made  to  volume  (30  c.c.),  and  centri- 
fuged.  After  this  is  done,  pour  the  slightly  col- 
ored supernatant  fluid  into  a  dry  centrifuge  tube 
and  add  about  six  drops  of  a  strong  solution  of 
colloidal  iron  and  place  the  tube  in  a  beaker  of 
hot  water  for  a  few  minutes.  This  brings  about  a 
complete  precipitation  of  all  protein.  After  cen- 
trifuging  (or  filtering)  the  clear  fluid  once  more, 
pour  it  from  the  tube  and  take  10  c.c.  (equavalent 
of  1  c.c.  of  blood)  into  a  50  c.c.  evaporating  dish 
or  a  25  c.c.  volumetric  flask,  depending  on  the 
method  used,  and  titrate. 

"Theoretically  the  Volhard- Arnold  is  to  be  pre- 
ferred, but  the  substances  which  may  interfere 
with  the  Mohr  titration  are  so  small  that  the  re- 
sults are  practically  identical.  The  former  method 
of  advantage,  however,  when  for  any  reason  the 
fluid  to  be  titrated  has  been  rendered  acid. ' ' 

Volhard-Arnold  Method. 

Pipette  10  c.c.  of  the  filtrate  into  a  25  c.c.  volumetric ,  flask. 
Add  10  c.c.  of  the  standard  silver  nitrate  solution2  (1  c.c.  =  0.001 
gm.  of  sodium  chloride)  and  1  c.c.  of  the  ferric  alum  indicator,3 


1Myers  and  Fine:  Chemical  Composition  of  the  Blood  in  Health  and  Disease,  New 
York,  1915. 

:This  standard  is  prepared  by  dissolving  2.906  gms.  of  silver  nitrate  in  distilled  water 
and  making  up  to  1  liter. 

3The  indicator  is  made  by  dissolving  100  gms.  of  crvstalline  ferric  ammonium  sulphate 
in  100  c.c.  of  25%  nitric  acid. 

57 


58  BLOOD   AND    URINE    CHEMISTRY 

and  finally  make  up  to  volume  and  shake  thoroughly.  Cen- 
trifuge this  in  a  large  (50  c.c.)  centrifuge  tube  and  decant  the 
clear  supernatant  fluid.  Titrate  20  c.c.  of  the  fluid,  which  is  the 
equivalent4  of  0.8  c.c.  of  blood,  with  a  standard  ammonium  thio- 
cyanate  solution  of  the  same  strength  as  the  silver  nitrate,  until  a 
distinct  yellow  color  shows  throughout  the  mixture.  The  titration 
result,  divided  by  0.8,  subtracted  from  10,  to  obtain  the  silver 
nitrate  used,  and  multiplied  by  .001,  and  again  multiplied  by  100 
gives  the  percentage  of  chlorides  as  sodium  chloride. 

Example. — Reading  on  burette  is  3.2  c.c.  Divide  by  0.8  =  4; 
subtract  from  10  =  6;  multiply  by  0.001  =  0.006  (gms.  of  NaCl  in 
1  c.c.  of  blood)  ;  multiply  by  100  =  0.6%  (normal). 

Mohr  Method. 

Pipette  10  c.c.  of  the  filtrate  into  an  evaporating  dish  of  50 
c.c.  capacity  and  add  one  drop  of  a  10%  solution  of  potassium 
chromate.  Now  run  the  standard  silver  nitrate  (same  as  above,  1 
c.c.  equals  0.001  gm.  of  sodium  chloride)  into  the  dish  from  a 
burette  until  the  first  permanent  precipitate  of  silver  chromate, 
which  is  an  orange-red  color,  shows  throughout  the  whole  solu- 
tion on  stirring.  This  is  the  end  of  the  titration,  for  which  there 
is  a  correction  of  0.2  to  0.3  of  1  c.c.  This  result  multiplied  by 
0.001,  multiplied  by  100  gives  the  percentage  of  chlorides  as  so- 
dium chloride. 

Example. — Reading  on  burette  is  6.3  c.c.  Subtract  0.3  c.c., 
equals  6  (corrected  reading)  ;  multiply  by  0.001  equals  0.006  (gms. 
of  NaCl  in  1  c.c.  of  blood)  ;  multiply  by  100  equals  0.6%  (normal). 

Standard  ammonium  thiocyanate  is  prepared  by  dissolving  1.3  gms.  of  ammonium 
thiocyanate  in  800  c.c.  of  water,  titrating  against  the  above  silver  nitrate  standard,  and 
ascertaining  the  amount  of  water  which  must  be  added  to  the  solution  to  make  it  equiv- 
alent to  1  c.c.  of  the  standard  silver  nitrate  solution  or  0.001  gm.  of  sodium  chloride, 


CHAPTER  XII 
LIPOIDS 

The  method  given  here  is  the  latest  technic  employed  by  Bloor 
who  published  his  original  method  in  1914.1  It  is  a  modification 
of  the  original  method.  It  is  taken  from  the  description  written  by 
Bloor  himself  in  Joslin's  latest  work.2 

The  method  depends  upon  a  new  principle — the  determination 
of  the  fat  by  precipitation  in  a  water  solution  and  comparison  of 
the  cloudy  suspension  so  obtained  with  that  of  a  similarly  prepared 
standard  fat  solution  by  the  use  of  the  nephelometer.  The  deter- 
mination may  be  completed  in  about  three-quarters  of  an  hour  and 
may  be  carried  out  with  from  0.5  c.c.  to  5  c.c.  of  blood.  Ordinarily 
about  2  c.c.  are  used.  It  has  been  found  to  be  accurate  Avithin  5 
per  cent  of  the  total  fat.  The  technic  is  as  follows : 

Extraction. — Three  c.e.  of  freshly  drawn  and  well-mixed  blood 
are  run  in  a  slow  stream  of  drops  into  a  graduated  flask  containing 
about  80  c.c.  of  a  mixture  of  3  parts  alcohol  and  1  part  ether  (both 
redistilled)  which  is  kept  in  constant  motion  by  rotating  the  flask. 
The  solution  is  raised  to  boiling  by  immersion  in  a  water-bath 
(with  frequent  shaking  to  prevent  superheating)  cooled  to  room 
temperature,  made  up  to  volume  with  alcohol-ether,  mixed  and 
filtered.  The  extract  if  placed  in  tightly  stoppered  bottles  in  the 
dark  will  keep  several  months  unchanged. 

Determination. — From  5  to  20  c.c.  (ordinarily  10  c.c.)  of  the 
extract,  containing  2  mg.  of  fat,  are  measured  with  a  pipette  into 
a  small  beaker  and  saponified  by  evaporating  just  to  dryness  with 
2  c.c.  of  N/l  sodium  ethylate  (made  by  dissolving  cleaned  metallic 
sodium  in  absolute  alcohol).  After  evaporation  is  complete  5  c.c. 
of  alcohol-ether  are  added  and  the  mixture  heated  slowly  to  boil- 
ing. A  similar  solution  of  the  standard  is  prepared  by  measuring 
5  c.c.  of  the  standard  fat  solution  (see  below)  into  a  beaker  and 
heating  to  boiling  as  above.  Fifty  c.c.  of  distilled  water  are  now 
added  to  each  beaker  and  the  solutions  mixed  by  stirring,  taking 


^loor:      Tour.    Biol.    Chem.,   1914,   xvii,   378. 

2Joslin:     Treatment  of  Diabetes  Mellitus,   Lea  &  Febiger,   1917,   p.   207. 

59 


60  BLOOD   AND    URINE    CHEMISTRY 

care  that  all  the  material  in  the  saponification  beaker  is  dissolved. 
To  standard  and  test  solutions  are  added,  as  nearly  simultaneously 
as  possible,  10  c.c.  portions  of  dilute  (1  to  4)  hydrochloric  acid  and 
the  solutions  allowed  to  stand  for  five  minutes,  after  which  they 
are  transferred  to  the  comparison  tubes  of  the  nephelometer. 

If  bubbles  appear  on  the  walls  of  the  tubes,  they  should  be  moved 
by  inverting  the  tubes  two  or  three  times.  The  movable  jacket  on 
the  standard  tube  is  set  at  a  convenient  point,  generally  50  mm. 
(Richard's  nephelometer)  and  comparisons  made  by  adjusting  the 
jacket  on  the  test  solution  until  the  images  of  the  two  solutions 
show  equal  illumination.  Not  less  than  five  readings  are  taken, 
alternately  from  above  and  below,  and  the  average  taken  as  the 
correct  reading. 

The  standard  solution  is  an  alcohol-ether  solution  of  pure  trio- 
lein  of  which  5  c.c.  contain  about  2  mg.  of  fat.  The  alcohol  and 
ether  used  for  the  standard  are  freshly  distilled  absolute  alcohol 
and  pure  dry  ether. 


CHAPTER  XIII. 
TESTS  FOR  ACIDOSIS  IN  BLOOD. 

Van  Slyke  Method  for  the  Determination  of  the  Carbon  Dioxide 
Combining  Power  of  Blood  Plasma. 

Having  ceiitrifuged  the  fresh  oxalated  blood,  pipette  off  the  clear 
plasma  and  place  in  a  separately  funnel  of  about  300  c.c.  capac- 
ity. Slight  heraolysis  does  not  affect  results  appreciably,  but 
hemolysis  should  be  avoided  as  much  as  possible  by  immediate 
centrifugalization.  In  order  to  determine  its  alkaline  reserve,  sat- 
urate the  plasma  with  carbon  dioxide  at  alveolar  tension.  In 
other  words,  the  operator  blows  vigorously  through  a  bottle  con- 
taining glass  beads  into  the  separatory  funnel,  as  shown  in  Fig. 
23.  If  one  blows  directly  into  the  separatory  funnel,  enough  mois- 
ture condenses  on  the  walls  of  the  funnel  to  appreciably  dilute 
the  plasma.  Close  the  funnel  at  stop-cock  S  and  stopper  T  just 
before  the  stream  of  breath  stops,  and  shake  for  one  minute  in  such 
a  manner  that  the  plasma  is  distributed  as  completely  as  possible 
about  the  walls.  After  the  shaking  has  lasted  a  minute,  blow  a 
fresh  portion  of  the  alveolar  air  through  the  beads  into  the  fun- 
nel and  shake  for  one  minute. 

The  C02  (Fig.  24)  apparatus  is  held  in  a  strong  clamp  W, 
which  is  lined  with  rubber,  and  the  lower  stop-cock  is  supported 
by  an  iron  rod,  which  is  also  covered  with  soft  rubber  tubing. 
The  apparatus  is  completely  filled  with  mercury.  Care  should  be 
taken  that  capillaries  A  and  F,  which  are  above  the  upper  stop- 
cock, are  also  filled  with  mercury.  There  should  be  no  air  bub- 
bles within  the  apparatus.  Six  dropping  bottles,  which  contain 
the  following- solutions,  should  be  at  hand  (see  Fig.  25)  : 

1.  Distilled  water. 

2.  Phenolphthalein    (1%  in  95%   alcohol). 

3.  Normal  ammonium  hydroxide. 

4.  Caprylic  alcohol  or  phenyl  ether. 

5.  Normal  sulphuric  acid. 

6.  Mercury. 

61 


62 


BLOOD   AND    URINE    CHEMISTRY 


V-* 


C5 


TESTS   FOR  ACIDOSIS   IN   BLOOD 


63 


Fig.  24.— COa  apparatus. 


04 


BLOOD    AND    URINE    CHEMISTRY 


The  mercury  leveling  bulb  H  should  be  hung  by  wire  1  on  ex- 
tension N,  about  on  the  level  with  the  lower  cock  J.  The  appa- 
ratus must  be  thoroughly  cleaned  before  the  determination  is 
started.  The  apparatus  can  be  tested  by  allowing  the  mercury 
to  run  down  and  then  forcing  it  up  by  raising  and  lowering  bulb 
//.  The  air  is  forced  out  and  the  mercury  is  caught  in  a  bottle 
as  shown  in  Fig.  26.  (This  is  done  until  there  is  not  a  single  air 
bubble  in  the  apparatus.)  Add  one  drop  of  phenolphthalein  to 
the  upper  cup  B  and  a  drop  or  two  of  the  ammonium  hydroxide. 
Now  dilute  this  with  about  1/2  c-c-  °f  distilled  water  and  draw  off 
all  except  about  two  drops  of  the  alkaline  solution. 

Now  introduce  1  c.c.  of  the  saturated  plasma  into  the  cup  and 
allow  it  to  flow  under  the  alkaline  solution,  so  that  none  of  the 


Fig.    25. — Dropping   bottles    for    use    in    connection    with    CO2    determination. 

carbon  dioxide  escapes.  Turn  stop-cock  C  so  that  E  and  Z 
are  connected  and  allow  the  plasma  to  run  in  until  capillary  F  is 
exactly  filled.  Add  0.5  c.c.  of  distilled  water  to  cup  B  and  then 
allow  to  run  down  to  capillary  F.  Repeat  this,  taking  care  that 
no  air  enters  the  apparatus  with  the  liquid.  Now  admit  into  capil- 
lary F,  1  drop  of  caprylic  alcohol  (see  footnote)  to  prevent  foam- 


Owing   to    the    scarcity    of   caprylic   alcohol,    and    the    impui 
alcohol,  which  is  often  sold,  we  have  found  the  us 


ies  in  secondary  caprylic 

,  „._,..-  of  phenyl  ether  to  be  just  as  effective 

in  this  test  as  caprylic  alcohol.  *  It  possesses  the  advantages  of  prevention  of  foaming, 
does  not  absorb  gas,  and  can  be  readily  manufactured  at  comparatively  low  cost. 

Mitchell  and  Eckstein  (Jour.  Biol.  Chem.,  March,  1918,  xxxiii,  No.  3)  describe  the  use 
of  phenyl  ether  and  its  manufacture,  with  full  details.  They  have  used  the  method  of 
Ullman  and  Sponagel  (Ullman,  F.,  and  Sponagel,  P.,  Berl.  chem.  Ges  .  1905,  xxxviii, 
2211)  with  satisfactory  results.  The  method  described  by  them  is  as  follows: 

Into  a  1.5  liter  round  bottomed  flask  are  weighed  560  gm.  of  hromobenzine,  420  gm. 
of  phenol,  221  gm.  of  KOH,  and  3.5  gm.  of  copper  bronze.  This  mixture  is  heated  on 
an  oil  bath  at  210-230  C.  for  about  2.5  hours  under  a  reflux  condenser.  We  have 
used  as  a  condenser  a  30  inch  glass  tube  of  J4  inch  bore,  tonped  by  a  water  condenser 
of  equal  length.  Even  with  this  arrangement  it  is  difficult  if  not  impossible  to  prevent 
some  loss  of  bromobenzene,  especially  during  the  early  stages  of  heating.  The  mixture 


TESTS   FOR   ACIDOSIS   IN   BLOOD  65 

ing,  and  pour  about  1.5  c.c.  of  the  sulphuric  acid  into  the  cup.  Ad- 
mit enough  of  the  acid  into  the  apparatus,  carrying  the  caprylic 
alcohol  along  with  it,  so  that  the  total  volume  in  the  apparatus  is 
exactly  to  the  2.5  c.c.  mark.  Draw  off  the  excess  sulphuric  acid. 
Now  place  a  few  drops  of  mercury  in  cup  B  and  allow  to  flow  down 
to  capillary  F,  in  order  to  seal  same  and  make  it  capable  of  holding 
an  absolute  vacuum.  During  this  whole  operation,  the  lower  stop-cock 
J  should  remain  open,  and  when  the  apparatus  is  set  up,  it  should 
be  in  such  adjustment  that,  if  the  wire  /  which  is  connected  to 
bulb  H  is  lowered  to  hook  0,  the  mercury  will  run  to  the  mark  X  on 
the  figure  (Fig.  27),  care  being  taken  that  the  mercury  will  not  run 
into  fork  Y.  Place  wire  /  on  hook  0  and  allow  the  mercury  to  fall 
until  the  meniscus  of  the  mercury  has  dropped  to  the  50  c.c.  mark 
on  the  apparatus.  This  is  controlled  by  stop-cock  J.  The  bubbles 
of  C02  are  now  seen  escaping. 

In  order  to  completely  extract  the  carbon  dioxide,  remove  the 
apparatus  from  the  clamp  and  shake  by  turning  it  upside  down 
about  a  dozen  times.  ( The  thumb  should  be  placed  over  cup  B  so 
as  not  to  lose  any  of  the  mercury.)  Then  replace  the  apparatus, 
the  mercury  leveling  bulb  H  still  being  at  the  low  level  0,  and  al- 
low the  solution  to  flow  into  the  small  bulb  below  the  lower  stop- 
cock (right  side) .  Drain  the  solution  out  of  the  portion  of  the  appa- 
ratus above  the  stop-cock  J  as  completely  as  possible,  but  without 
removing  any  of  the  gas  (the  last  drop  being  allowed  to  remain 
above).  Now  raise  the  mercury  bulb  H  in  the  left  hand,  and 
with  the  right  hand  immediately  turn  the  lower  stop-cock  J,  so 
that  the  mercury  is  admitted  to  the  upper  part  of  the  apparatus 
through  the  left-hand  entrance  of  the  stop-cock  without  readmit- 


is  then  distilled  with  steam.  The  distillate  is  separated  in  a  separatory  funnel,  and  the 
heavy  oil  at  the  bottom  fractionally  distilled.  The  boiling  point  of  phenyl  ether  is  252.3 
C.  We  have  taken  off  fractions  from  244-261°  C.  for  use. 

The  yield  may  be  increased  greatly,  at  least  if  the  steam  distillation  has  not  been 
carried  to  completion,  by  extracting  the  residue  from  the  steam  distillation,  in  small 
portions,  with  ether,  three  washings  for  each  portion  being  sufficient.  The  ether  ex- 
tracts are  then  distilled.  A  careful  and  repeated  fractionation  of  the  oil  from  the  steam 
distillation  and  of  the  material  extracted  by  ether  from  the  residue  is  advantageous. 
After  several  fractionations  it  will  be  found  that  most  of  the  material  falls  into  two 
fractions,  namely,  from  150-168°,  and  from  244-261°  C.,  the  former  fraction  being 
bromobenzine  and  the  latter  phenyl  ether.  From  the  quantities  of  chemicals  given  above, 
we  have  obtained  287  gm.  of  phenyl  ether,  representing  a  yield  of  47.5  per  cent  of  the 
theoretical,  figured  on  the  basis  of  560  gm.  of  bromobenzine,  or  of  73  per  cent  when  from 
the  amount  of  bromobenzine  taken  that  recovered  in  the  final  fractional  d-'stillation  (?00 
gm.,  boiling  from  150-168°)  is  deducted.  The  relatively  large  amount  of  bromobenzine 
thus  recovered  would  suggest  that  the  time  of  refluxing  at  210-230°  could  be  lengthened 
considerably  to  advantage. 

Phenyl  ether  melts  at  28°  C.,  but  when  in  the  liquid  state  it  may  be  supercooled 
considerably  without  solidifying.  We  have  observed  no  solidification  of  our  product  at 
temperature  above  20°  C. 


66 


BLOOD   AND    URINE    CHEMISTRY 


TESTS    FOR    ACIDOSIS   IN    BLOOD 


Fig.  27. — CO2  apparatus.     Mercury  should  not  go  below  mark  X. 


68  BLOOD   AND   URINE    CHEMISTRY 

ting  the  watery  solution.  Hold  the  leveling  bulb  H  beside  the  ap- 
paratus so  that  its  mercury  level  corresponds  to  that  in  the  ap- 
paratus, and  the  gas  in  the  latter  is  under  atmospheric  pressure. 
A  few  hundredths  of  a  cubic  centimeter  of  water  will  float  on  the 
mercury  in  the  apparatus,  but  this  may  be  disregarded  in  leveling. 
The  calculation  of  the  result  into  terms  of  volume  percentage  of 
carbon  dioxide,  bound  as  carbonate  by  the  plasma,  is  quite  com- 
plicated and  we  consequently  use  the  direct  reading  from  the 
apparatus,  minus  .12. 

Plasma  of  normal  adults  yield  0.65  c.c.  to  .90  c.c.  of  gas  which 
is  the  direct  reading  on  the  apparatus.  If  .12  were  subtracted, 
the  normal  figures  would  be  53  to  78  in  terms  of  volume  per  cent 
of  carbon  dioxide  chemically  bound  by  the  plasma.  Figures  lower 
than  50  per  cent  in  adults  indicate  acidosis.  The  exact  calcula- 
tion of  the  result  into  terms  of  carbon  dioxide  bound  as  carbon- 
ate by  the  plasma  is  quite  complicated  and  consequently  the 
worker  is  advised  to  subtract  .12  from  his  reading  on  the  appa- 
ratus. The  result  thus  obtained  gives  approximately  (within  2  to 
3  per  cent)  the  volume  per  cent  of  carbon  dioxide  bound  by  the 
plasma. 

Example. — Reading  on  the  Van  Slyke  apparatus  is  0.74  minus 
0.12  which  equals  0.62  per  cent  of  carbon  dioxide  bound  by  1  c.c. 
of  plasma.  For  100  c.c.  of  plasma  multiply  0.62%  by  100,  which 
equals  62%  (normal). 

Marriott,  Levy,  and  Rowntree  Method  for  the  Determination  of 
the  Hydrogen-ion  Concentration  of  the  Blood. 

Principle  of  the  Method. — Levy,  Rowntree,  and  Marriott1  state 
that  the  indicator  method  has  not  proved  of  great  value  in  the 
studies  of  hydrogen-ion  concentration  of  the  blood,  although  the 
reaction  of  inorganic  solutions  may  be  determined  accurately  by 
this  means.2  Different  indicators  show  their  color  changes  at  vary- 
ing degrees  of  hydrogen-ion  concentration :  for  example,  the  color 
of  methyl  orange  changes  from  pink  to  yellow  as  the  pH  of  its 
solution  changes  from  3  to  5.  At  intermediate  points,  various 
colors  may  be  obtained  and  a  certain  color  indicates  a  definite  pH. 

"Levy,  Rowntree,  and  Marriott:     Arch,  of  Int.  Med.,  1915,  vol.  xvi,  p.  389. 
zS6renson:      Ergebn.   d.    Physiol.,   1912,   vol.    xii,    393.      A   full   description    of   indicators 
as  used  for  this  purpose. 


TESTS  FOR  ACIDOSIS   IN   BLOOD  69 

Similarly,  phenolphthalein  changes  from  colorless  to  pink  between 
pH8  and  pHIO  and  can  be  used  for  the  measurement  of  H-ion 
concentrations  between  these  two  points.  In  carrying  out  the  in- 
dicator method,  it  is  necessary  to  have  a  series  of  standard  solutions 
of  known  pH  and  an  indicator  exhibiting  easily  distinguishable 
color  changes  at  hydrogen-ion  concentrations  approximating  that 
of  the  solution  under  consideration.  It  is  then  simply  necessary 
to  add  equal  amounts  of  indicator  to  the  standard  solutions  and  to 
the  solution  being  tested  and  to  determine  which  of  the  colors  in 
the  standard  solutions  most  closely  matches  that  of  the  unknown 
solution. 

This  method  has  been  successfully  used  on  the  urine  by  Render- 
son  and  by  Walpole.  As  proteins  interfere  with  the  colors  of  many 
indicators,  and  as  both  blood  and  serum  possess  color,  it  has  been 
impossible  to  apply  the  method  directly  to  the  blood. 

It  seemed  probable  that  the  indicator  method  might  be  utilized 
for  blood,  provided  coloring  matters  and  proteins  could  be  ex- 
cluded by  means  of  dialysis.  If  blood  is  dropped  into  collodion  sacks 
and  dialyzed  for  five  minutes,  the  dialysate  is  free  from  proteins 
and  coloring  matter,  but  contains  salts,  and  is  well  adapted  to 
the  use  of  indicators. 

Since  phenolsulphonphthalein  exhibits  definite  variations  in 
quality  of  color,  with  very  minute  differences  in  hydrogen-ion  con- 
centration between  pH6.4  and  $.4,  it  was  adopted  as  the  indicator 
in  this  method. 

Preparation  of  Standard  Colors.— Standard  phosphate  mixtures 
are  prepared  according  to  Sorenson's  directions  as  follows: 

One-fifteenth  Molecular  .Acid  or  Primary  Potassium  Phosphate.— 
Dissolve  9.078  grams  of  the  pure  recrystallized  salt  (KH2P04), 
in  freshly  distilled  water  and  make  up  to  one  liter. 

One-fifteenth  Molecular  Alkaline  or  Secondary  Sodium  Phos- 
phate.— Expose  the  pure  recrystallized  salt  (Na,HP04.12H20)  to 
the  air  for  from  ten  days  to  two  weeks,  protected  from  dust. .,  Ten 
molecules  of  water  of  crystallization  are  given  off  and  a  salt  of  the 
formula  Na2HP04.2H20  is  obtained;  dissolve  11.876  grams  of 
this  in  freshly  distilled  water  and  make  up  to  one  liter.  The 
solution  should  give  a  deep  rose  red  color  with  phenolphthalein. 
If  only  a  faint  pink  color  is  obtained,  the  salt  is  not  sufficiently 
pure. 


70 


BLOOD    AND    URINE    CHEMISTRY 


Mix  the  solutions  in  the  proportions  indicated  below  to  obtain 
the  desired  pH: 


pH 

6-4|  6.6|  6.8 

7.0   7.1    7.2|  7.3 

7.4 

7.5   7.6   7.7 

7,S 

8.0 

8.2 

8.4 

Primary 
Potas. 
Phos.  c. 
Secondary 
Sodium 
Phos.  c. 

73.0 
27.0 

63.0 
37.0 

51.0 
49.0 

37.0 
63.0 

32.0 
68.0 

27.023.0 
73.o'77.0 

19.0 
81.0 

15.8  13.2 
84.286.8 

11.0 
89.0 

8.8 
91.2 

5.6   3.2 
94.4  96.8 

2.0 
98.0 

Place  three  c.c.  of  each  of  the  solutions  in  suitable  small  test 
tubes  (100x10  mm.,  inside  measurement).  Add  five  drops  of  an 
aqueous  0.01  per  cent  solution  of  phenolsulphoiiphthalein  to  each 
tube.  Seal  off  the  tops.  The  series  of  colors,  representing  differ- 
ent concentrations  of  hydrogen-ions,  constitutes  the  standards  for 
comparison  of  color  in  carrying  out  the  determination. 

Preparation  of  Sacks. — Dissolve  one  ounce  of  collodion  (An- 
thony's negative  cotton)  in  500  c.c.  of  a  mixture  of  equal  quanti- 
ties of  ether  and  ethyl  alcohol.  The  solid  swells  up  and  dissolves 
with  occasional  gentle  shakings,  in  forty-eight  hours.  As  a  small 
amount  of  brown  sediment  separates  out  at  first,  the  solution  should 
stand  for  at  least  three  or  four  days,  after  which  the  clear  super- 
natant solution  is  ready  for  use.  Fill  a  small  test  tube  (120  by  9 
mm.,  inside  measurement)  with  this  mixture,  invert,  and  po.ur  out 
half  the  contents.  The  tube  is  then  righted,  and  the  collodion  al- 
lowed to  fill  the  lower  half  again.  Invert  a  second  time  and  rotate 
on  its  vertical  axis,  the  collodion  being  drained  off.  Care  must 
be  taken  to  rotate  the  tube,  in  order  to  secure  a  uniform  thickness 
throughout.  Clamp  the  tube  in  the  inverted  position  and  allow  to 
stand  for  ten  minutes,  until  the  odor  of  ether  finally  disappears. 
Fill  it  five  or  six  times  with  cold  water,  or  allow  it  to  soak  five 
minutes  in  cold  water.  Run  a  knife  blade  around  the  upper  rim, 
so  as  to  loosen  the  sack  from  the  rim  of  the  test  tube,  and  run  a 
few  cubic  centimeters  of  water  down  between  the  sack  and  the 
glass  of  the  tube.  Extract  the  tube  by  gentle  pulling,  after  which 
preserve  by  complete  immersion  in  water. 

The  Salt  Solution  Used  in  the  Method.— Dialyze  the  blood  or 
serum  against  an  0.8  per  cent  sodium  chloride  solution. 


TESTS   FOR   ACIDOSIS    IN    BLOOD  71 

Before  applying  the  test,  it  is  necessary  to  ascertain  that  the 
solution  is  free  from  acids  other  than  carbonic.  To  determine  this, 
place  a  few  cubic  centimeters  of  the  salt  solution  in  a  Jena  test  tube 
and  add  one  or  two  drops  of  the  indicator,  whereupon  a  yellow 
color  will  appear.  On  boiling,  carbon  dioxide  is  expelled,  and  the 
solution  loses  its  lemon  color  and  takes  on  a  slightly  brownish 
tint.  In  the  absence  of  this  change,  other  acids  are  present,  and 
the  salt  solution  is  therefore  not  suitable.  If,  on  the  other  hand, 
on  adding  the  indicator,  pink  at  once  appears,  the  solution  is  alka- 
line and  hence  cannot  be  used. 

Technic  of  Method. — The  technic  can  be  carried  out  on  either 
serum,  plasma,  whole,  or  defibrinated  blood.  The  work  must  be 
done  in  a  room  free  from  fumes  of  acids  or  ammonia. 

Run  one  to  three  c.c.  of  clear  serum  or  of  blood,  by  means  of  a 
blunt  pointed  pipette,  into  a  dialyzing  sack  which  has  been  washed 
inside  and  outside  with  salt  solution  and  which  has  been  tested  for 
leaks  by  filling  with  the  salt  solution.  Lower  the  sack  into  a  small 
test  tube  (100  by  100  mm.,  inside  measurement)  containing  3  c.c. 
of  the  salt  solution,  until  the  fluid  on  the  outside  of  the  sack  is  as 
high  as  on  the  inside.  Allow  from  five  to  ten  minutes  for  dialysis. 
Remove  the  collodion  sack  and  add  5  drops  of  the  indicator  thor- 
oughly mixed  with  the  dialysate.  Then  compare  the  tube  with  the 
series  of  standards  until  the  corresponding  color  is  found,  which 
indicates  the  hydrogen-ion  concentration  present  in  the  dialysate. 

These  tests  have  been  carried  out  with  3  c.c.  of  blood  or  serum. 
The  same  results  are  obtained  with  1  c.c.  of  blood  or  serum  on 
the  inside  of  the  sack  and  with  this  amount  it  is  immaterial  whether 
there  is  1  or  3  c.c.  of  salt  solution  on  the  outside. 

Comparison  of  Tubes  With  Standards.— For  this,  a  good  light 
(natural  or  artificial)  and  a  white  background  are  requisites. 
Readings  must  be  made  immediately.  The  tube  matching  most 
closely  is  selected  and  also  the  tubes  on  either  side  of  it.  These 
are  critically  inspected  against  a  white  background.  Changing  the 
order  of  the  tubes  often  makes  differences  more  apparent. 

Controls  of  the  Method. — Repeated  duplicate  determinations  on 
the  same  samples  of  blood  and  of  serum  have  convinced  Marriott 
and  his  co-workers  that  the  limits  of  error  are  very  slight :  for  ex- 
ample, the  scrum  from  a  case  of  mild  acidosis  (using  quantities 


72  BLOOD   AND   URINE    CHEMISTRY 

of  serum  varying  from  1  to  3  c.c.  and  dialyzing  for  from  five  to 
fifteen  minutes)  gave  the  following  scries  of  readings:,  7. 55,  7.55, 
7.55,  7.55,  7.6,  7.55,  7.55,  7.55,  7.55,  7.55.  The  oxalated  whole  blood 
from  the  same  case  gave  the  following  readings  under  similar  con- 
ditions: 7.25,  7.25,  7.25,  7.25,  7.2,  7.25,  7.25,  7.3,  7.25,  7.25.  7.25, 
7.25,  7.25,  7.25. 

In  order  to  test  out  the  effect  of  the  variations  in  the  sacks  used, 
a  number  of  determinations  were  made  on  the  same  sample  of 
serum  with  the  following  results :  ordinary  thin  sack,  7.7 ;  thick 
sack,  7.7 ;  opaque,  irregular  sack,  7.7 ;  ordinary  thin  sack,  7.65 ;  a 
very  thick  sack,  7.7.  A  series  of  six  normal  serums  were  run 
through,  3  c.c.  and  1  c.c.  portions  being  used  for  dialysis.  In  every 
instance  identical  readings  were  obtained. 

A  brief  word  of  explanation  may  be  given  for  those  unaccus- 
tomed to  the  physicochemical  methods  of  expressing  the  reaction 
of  a  solution.  A  solution  is  acid  when  it  contains  an  excess  of 
hydrogen  over  hydroxyl-ions,  neutral  when  hydrogen-  and  hy- 
droxyl-ions  are  in  equal  numbers,  and  alkaline  when  hydroxyl-ions 
predominate.  An  acid  of  "normal"  strength  contains,  in  one  liter, 
a  gram  of  hydrogen  capable  of  forming  hydrogen-ions  and  its 
strength  may  be  expressed  as  1  N.  Diluting  such  a  solution  ten 
times,  we  would  have  1/10  N  or  a  solution  containing  1/10  gram 
of  actual  or  potential  hydrogen-ions  to  the  liter.  Continuing  the 
process  of  dilution  until  1/10,000,000  normal  acid  is  obtained,  we 
would  have  in  such  a  solution  1/10,000,000  gram  of  hydrogen-ions. 
Pure  water,  however,  dissociates  to  form  hydrogen-  and  hydroxyl- 
ions,  and  at  20°  C.  contains  approximately  1/10,000,000  gram  of 
hydrogen-ions  to  the  liter  and  an  equivalent  amount  of  hydroxyl- 
ions  (that  is,  17  gm.).  That  is  to  say,  pure  water,  our  standard 
of  neutrality,  is  1/10,000,000  N  aeid  and  also  1/10,000,000  N  alka- 
line. To  avoid  writing  large  figures  it  is  customary  to  use  the 
logarithmic  notation  and  to  express  1/10,000,000  N  as  10— 7N  or 
more  conveniently,  as  suggested  by  Sorenson,  to  drop  the  10  and 
minus  sign  and  say  pH7.  If  we  have  less  than  1/10,000,000 
gram  of  hydrogen-ions  in  one  liter  the  solution  is  less  acid  than 
water,  that  is,  it  is  alkaline — so,  pH8  means  actually  1/10,000,000 
N  alkali.  The  higher  the  exponent,  the  more  the  alkaline,  or  wnat 
is  saying  the  same  thing,  the  less  acid  the  solution. 


TESTS   FOR   ACIDOSIS   IN   BLOOD  73 

To  sum  up : 

pHl=N/10  acid. 


pH6=N/l,000,000  acid. 
pH7=NEUTBALITY. 

pH8=N/l,000,000  alkali. 


pH14:=N/10  alkali. 

The  reaction  of  the  blood  serum  varies  approximately  between 
pH7  and  pH8,  the  neutral  point,  pH7  being  reached  only  in  severe 
uncompensated  acidosis,  and  a  reaction  of  pH8  being  attained 
perhaps  only  after  administration  of  alkalies.* 

The  Determination  of  the  Alkali  Reserve  of  the  Blood  Plasma. 

Marriott  has  recently3  published  a  method  which  gives  the  hydro- 
gen-ion concentration  of  the  dialysate  of  blood  serum  after  re- 
moval of  the  carbon  dioxide,  that  is  in  a  measure  a  modification  of 
the  indicator  analysis  of  the  preceding  test,  but  is  more  accurate 
and  gives  more  information  than  that  method.  This  method  serves 
for  the  detection  and  accurate  quantitative  estimation  of  the  de- 
gree of  the  acidosis. 

Apparatus  Required. — Set  of  tubes  containing  standard  phos- 
phate mixtures;  a  solution  of  phenolsulphonphthalein  in  0.8  per 
cent.  Sodium  chloride ;  collodion  sacks ;  pipette  to  measure  0.5  c.c. ; 
small  test  tubes  for  dialyzing  and  aerating ;  atomizer  bulb ;  glass 
tube  or  pipette  drawn  out  to  a  fine  capillary  point;  color  com- 
parison box. 

Preparation  of  Phosphate  Mixtures — One-fifteenth  Molecular 
Acid  Potassium  Phosphate. — Dissolve  9.078  gms.  of  the  pure  re- 
crystallized  salt  (KH2P04)  in  freshly  distilled  water.  Add  200  c.c. 
of  0.01  per.  cent  phenolsulphonphthalein  and  make  up  the  whole  to 
1  liter  with  distilled  water. 

One-fifteenth  Molecular  Alkaline  Sodium  Phosphate. — Expose 
the  pure,  recrystallized  salt  (Na,HP04.12H20)  to  the  air  for  from 
ten  days  to  two  weeks,  protected  from  dust.  Ten  molecules  of 

sMarriott:     Arch.  Int.  Med.,  June,  1916,  vol.  xvii,  pp.  840-8S1. 

*The  apparatus  and  reagents  for  making  this  test  can  be  obtained  in  convenient  form 
from  Hynson,  Westcott  &  Dunning,  Baltimore,  Md. 


/4  BLOOD   AND    URINE    CHEMISTRY 

water  of  crystallization  are  given  off  and  a  salt  of  tKe  formula 
Na2HP04.2H20  is  obtained.  Dissolve  11.876  gms.  of  this  salt 
in  distilled  water.  Add  200  c.c.  of  0.01  per  cent  of  phenolsulphon- 
phthalein  and  make  up  the  whole  to  one  liter.  The  exact  amount 
of  indicator  is  immaterial,  provided  the  same  amount  of  indicator 
is  added  to  each  of  the  phosphate  solutions,  and  a  corresponding 
amount  is  added  to  the  salt  solution,  to  be  subsequently  described. 
Add  a  small  crystal  of  thymol  to  each  solution  to  prevent  the 
growth  of  molds.  The  solutions  should  be  preserved  in  Jena  or 
Non-sol  glass  vessels.  Mix  the  solutions  in  the  proportions  indi- 
cated below  to  obtain  the  desired  pH. 


pH  •  |    7.0  |    7.2  |    7.4  |    7.6  |    7.8  |    8.0  |    8.2  |    8.4  |    8.6 

''        '  ~'"T8  ^  |~5^"j~3.  27^270  |~1.0 


Secondary  sod.   phos7  c.c.    |  63.0  |  73.0  |  81.0  |  86.8  |l)lT294T4j96~8  "f987dj99."6 

Place  these  solutions  in  small  test  tubes,  approximately  100  mm. 
long  by  8  mm.,  internal  diameter,  of  glass  that  does  not  readily 
give  off  alkali.  The  tubes  are  stoppered  or  sealed  off.  They 
should  be  kept  in  a  dark  place  when  not  in  use.  Under  these  con- 
ditions, the  solutions  retain  their  colors  for  long  periods  of  time. 

Preparation  of  Salt  Solution.  —  Dissolve  8  gms.  of  chemically 
pure  sodium  chloride  in  distilled  water.  Add  220  c.c.4  of  0.01  per- 
cent phenolsulphonphthalein  solution  and  make  up  the  whole  to  one 
liter  with  distilled  water.  The  solution  should  contain  no  free 
alkali  and  no  acid  other  than  carbonic.  Test  the  solution  by  boil- 
ing a  little  of  it  for  a  minute  or  so  in  a  Jena  glass  test  tube,  in 
order  to  expel  carbonic  acid.5  Cool  the  solution  quickly  under  the 
tap  and  compare  with  the  phosphate  standards.  Its  reaction 
should  be  7.0.  If  the  reaction  differs  from  this,  it  may  be  cor- 
rected by  the  addition  of  a  few  drops  of  very  dilute  acid  or  alkali 
to  the  whole  solution.  The  salt  solution  must  be  kept  in  a  vessel 
of  Jena  or  Non-sol  glass,  or  in  a  vessel  of  ordinary  glass  that  has 
been  well  paraffined  on  the  inside. 

4The  concentration  of  indicator  in  the  salt  solution  is  purposely  made  10%  greater 
than  in  the  phosphate  mixtures,  as  during  the  dialysis  a  certain  amount  of  indicator  is 
lost  by  passing  into  the  sack. 

BIf  boiled  in  a  soft  glass  tube,  alkali  is  given  off  from  the  glass  and  the  solution  is 
colored  pink.  Instead  of  boiling  to  remove  carbon  dioxide,  the  solution  may  be  aerated 
with  a  current  of  air  that  has  been  freed  from  carbon  dioxide  by  passing  through  a 
strong  solution  of  sodium  hydroxide. 


TESTS  FOR  ACIDOSIS  IN  BLOOD  75 

METHOD  OF  DETERMINATION. — The  determination  must  be  car- 
ried out  in  a  room  free  from  acid  or  ammonia  fumes.  Either 
serum,  oxalated  plasma,  or  blood  may  be  used.  Serum  is  to  be 
preferred,  as  the  addition  of  oxalate,  unless  exactly  neutral,  intro- 
duces a  source  of  error.  The  blood  should  be  collected  in  a  small 
tube  and  the  serum  separated  as  quickly  as  possible,  preferably 
by  centrifuging.6  Hemolysis  must  be  avoided. 

Pipette  exactly  0.5  c.c.  of  serum  into  one  of  the  small  collodion 
sacks,  which  has  previously  been  washed  inside  and  out  with  the 
salt  solution.7  Lower  the  sack  into  a  small  test  tube,  approximately 
8  mm.  internal  diameter  and  50  mm.  long,  containing  2  c.c.  of  the 
indicator  salt  solution.  The  level  of  the  fluid  on  the  outside  of  the 
sack  should  be  at  least  as  high  as  that  on  the  inside.  At  the  end 
of  seven  minutes  remove  the  sack  and  transfer  the  dialysate  to  a 
clean  test  tube  100  to  140  mm.  long  and  having  the  same  diameter 
as  the  tubes  containing  the  phosphate  standards.  A  rapid  current 
of  air  is  bubbled  through  the  solution  in  order  to  remove  carbon 
dioxide.  This  is  accomplished  by  means  of  an  atomizer  bulb  con- 
nected with  a  narrow  glass  tube  drawn  out  to  a  capillary  point. 
The  air  current  should  be  as  rapid  as  possible  without  blowing 
liquid  out  of  the  test  tube.8  Continue  blowing  for  three  minutes 
and  then  compare  the  color  in  the  tube  with  that  in  the  standard 
phosphate  tubes,  interpolating  when  necessary.  The  reading  is  a 
measure  of  the  reserve  alkalinity.  For  convenience  of  expression 
this  value  is  referred  to  as  the  "RpH"  of  the  serum,  to  differen- 
tiate it  from  the  "pH"  as  determined  in  the  method  previously 
described  by  Levy,  Rowntree,  and  Marriott. 

RESULTS  OBTAINED. — Normal  Individuals.  The  serums  of  a 
large  number  of  normal  adults  were  examined  by  the  method  de- 
scribed. In  every  instance  the  RpH  was  found  to  be  8.5  ±  0.05, 
provided  the  subjects  examined  were  on  a  general  mixed  diet.  A 


6If  carbon  dioxide  escapes  from  the  plasma  as  a  result  of  shaking  or  allowing  the 
blood  to  remain  exposed  to  the  air,  a  passage  of  alkali  from  the  plasma  into-*  the  cells 
occurs  with  a  resultant  slight  diminution  in  the  alkali  reserve  of  the  plasma.  Once  the 
plasma  or  serum  is  separated  from  the  corpuscles,  loss  of  carbon  dioxide  is  without  effect 
on  the  alkali  reserve. 

7In  washing  the  sack,  no  part  but  the  top  edge  should  be  touched  with  the  fingers.  The 
sack  is  emptied  by  tipping  it  with  a  clean,  glass  rod  or  with  a  microscopic  slide.  Sacks 
may  be  used  more  than  once,  providing  they  are  thoroughly  washed  with  salt  solution 
after  each  test. 

"Foaming  rarely  occurs.  It  may  be  present  as  a  result  of  allowing  some  serum  to  spill 
over  the  outside  of  the  sack.  In  case  foaming  is  great  enough  to  be  troublesome,  it  may  be 
prevented  by  adding  a  drop  of  octyl  alcohol  or  toluol. 


76  BLOOD   AND   URINE    CHEMISTRY 

normal  adult's  serum  drawn  after  a  fast  of  sixteen  hours  gave  a 
reading  of  8.35.  The  serums  of  infants  gave  values  slightly  lower 
than  those  of  adults.  For  normal  infants  under  one  year  of  age,  a 
value  of  8.3  for  the  RpH  of  the  serum  was  not  infrequently  en- 
countered. This  may  be  due  partly  to  the  fact  that  infant's  blood 
is  usually  obtained  by  cupping;  the  lower  value,  however,  is  more 
likely  an  evidence  of  the  tendency  towards  acidosis  that  is  known 
to  be  present  in  infants. 

This  accords  well  with  the  observed  fact  that  the  carbon  dioxide 
tension  in  the  alveolar  air  of  infants  is  lower  than  that  of  adults, 
and  that  the  combined  carbon  dioxide  of  the  plasma  is  less  in  in- 
fants and  that  the  ammonia  co-efficient  in  the  urine  is  often  higher. 
This  slight  acidosis  might  well  be  the  result  of  the  more  active 
metabolism  of  infants,  leading  to  a  proportionately  greater  pro- 
duction of  acids. 

ACIDOSIS. — A  series  of  cases  exhibiting  clinical  or  laboratory  evi- 
dences of  acidosis  were  studied.  The  cases  included  nephritis  and 
diabetes  in  adults,  and  nephritis,  recurrent  and  idiopathic  aceto- 
nemia,  and  severe  diarrheas  in  children.  The  diarrheal  cases  were 
of  the  type  described  by  Howland  and  Marriott. 

In  all  the  cases  of  acidosis  studied,  the  RpH  of  the  serum  showed 
deviations  from  the  normal.  The  more  severe  the  acidosis,  as 
indicated  clinically  or  by  various  laboratory  methods,  the  lower 
were  the  figures  obtained  for  the  RpH.  Especially  striking  was  the 
parallelism  between  alveolar  carbon  dioxide  tension  and  the  RpH. 
The  two  values  should  correspond,  as  explained  above,  provided  the 
respiratory  center  does  not  vary  in  its  excitability  and  the  pul- 
monary epithelium  is  not  damaged  in  such  a  way  as  to  prevent 
equilibrium  being  attained  between  the  air  in  the  pulmonary  alveoli 
and  the  blood  in  the  pulmonary  capillaries.  Thus  a  hyperexcitable 
respiratory  center  should  lead  to  a  low  alveolar  carbon  dioxide 
tension,  with  a  coincident  normal  alkali  reserve.  A  diminished 
permeability  of  the  pulmonary  epithelium  would  result  in  a  lower- 
ing of  carbon  dioxide  tension  in  the  alveolar  air,  but  not  necessarily 
to  a  diminution  in  the  alkali  reserve  of  the  plasma. 

In  a  number  of  instances  the  combined  carbon  dioxide  of  the 
plasma  was  determined  according  to  the  method  described  by  Van 
Slyke.  The  results  obtained  were  in  a  general  way  proportional 
to  the  RpII  of  the  serum.  The  RpH  invariably  showed  an  increase 


TESTS  FOR  ACIDOSIS  IN  BLOOD  77 

following  administration  of  alkalies,  but  did  not  necessarily  reach 
its  normal  value.  It  was  in  connection  with  the  alkali  therapy 
that  Marriott  found  the  method  of  especial  value,  as  it  gave  infor- 
mation as  to  the  probable  amount  of  alkali  needed  to  replenish  the 
reserve.  A  determination  following  the  administration  of  alkali 
showed  whether  the  amount  was  sufficient. 

Interpretation  of  Results. — The  values  obtained  for  the  KpH 
of  the  serum  may,  in  the  light  of  his  experience,  be  interpreted  as 
follows : 

Values  for  the  RpH  of  from  8.4  to  8.55  correspond  to  alveolar 
carbon  dioxide  tensions  of  from  38  to  45  mm.,  and  are  to  be  con- 
sidered as  normal  values  for  adults.  Values  between  8.0  and  8.3 
correspond  to  alveolar  carbon  dioxide  tensions  of  from  28  to  35 
mm.,  and  indicate  a  moderate  degree  of  acidosis. 

When  the  value  for  RpH  is  as  low  as  7.7,  corresponding  to  an 
alveolar  carbon  dioxide  tension  of  20  mm.,  the  individual  is  in  im- 
minent danger.  During  coma,  an  RpH  as  low  as  7.3  corresponding 
to  an  alveolar  air  of  11  mm.,  was  observed.  In  infants  under  one 
year  of  age  a  value  for  RpH  of  8.3,  corresponding  to  35  mm.  ten- 
sion in  the  alveolar  air,  is  not  to  be  considered  abnormal. 

It  has  been  Marriott 's  experience  in  general  that  unless  the  RpH 
of  the  serum  is  below  7.9,  the  acidosis  may  be  successfully  combated 
by  dietetic  regulation  or  by  the  administration  of  alkali  by  mouth. 
When  the  RpH  of  the  serum  falls  below  7.9,  intravenous  adminis- 
tration of  alkali  is  usually  indicated. 

The   Determination  of  Beta-Hydroxybutyric   Acid,   Acetoacetic 
Acid,  and  Acetone  in  Blood 

Van  Slyke  and  Fitz  in  the  past  year  have  called  attention  to 
methods  of  determination  of  acetone  bodies  in  both  blood  and  urine 
that  are  quite  satisfactory.  It  is  necessary  to  remove  the  proteins 
from  the  blood  by  precipitating  them  at  room  temperature  with 
mercuric  sulphate  solution  (73  gm.  of  red  mercuric  oxide  dissolved 
in  1  liter  of  4  n  H2S04)  which  is  also  used  in  precipitating  the 
acetone  in  the  urine  tests  for  this  same  purpose.  The  mercury-pro- 
tein precipitate  leaves  no  interfering  substances  in  solution,  and 
it  absorbs  none  of  the  acetone  bodies :  both  beta-oxybutyric  acid  and 
acetone  added  to  blood  are  quantitatively  recovered  by  the  proc- 


78 


BLOOD    AND    URINE    CHEMISTRY 


ess  described  here :  of  whole  blood  10  c.c.  are  diluted  with  about 
100  c.c.  of  water  in  a  250  c.c.  flask,  and  20  c.c.  of  the  19  per  cent 
mercuric  sulphate  added.  Shake  for  a  moment  until  the  protein 
coagulates  and  then  dilute  with  water  up  to  the  250  c.c.  mark. 
After  15  minutes  filter  through  a  dry  folded  filter.  If  the  first 
drops  are  cloudy,  filter  a  second  time.  The  filtrate  has  a  slight 
pink  tinge,  but  the  substance  responsible  for  it  does  not  precipi- 
tate when  boiled  with  mercuric  sulphate  or  interfere  with  any 
of  the  acetone  body  determinations. 

For  the  estimation  of  these  bodies  in  plasma  or  serum,  take  8 
c.c.  of  oxalated  plasma  or  serum  with  50  c.c.  water  in  a  200  c.c. 
flask,  add  15  c.c.  of  the  mercuric  sulphate  solution.  Shake  for  a 
moment  until  the  fine  precipitate  which  has  flocculated  dissolves 
and  then  fill  to  the  mark  with  water.  After  standing  for  fifteen 
minutes  or  longer,  filter. 

Determinations.- — For  determination  of  acetone  plus  acetoacetic 
acid  of  beta-hydroxy butyric  acid,  or  of  the  total  acetone  bodies 
together,  125  c.c.  of  the  filtrate,  equivalent  to  5  c.c.  of  either  blood 
or  plasma,  may  be  treated  exactly  as  the  25  c.c.  of  urine  filtrate 
plus  100  c.c.  of  water  in  urine  analyses  (see  page  111). 

If  one  wishes  to  determine  separately  the  acetone  plus  the  aceto- 
acetic acid  and  the  hydroxybutyric  acid  in  a  single  sample  of  blood, 
this  may  be  done  by  precipitating  first  the  preformed  acetone  plus 
that  from  acetoacetic  acid,  and  then  determining  the  hydroxybu- 
tyric acid  in  the  filtrate.  The  preformed  acetone  plus  that  from 
acetoacetic  acid  is  precipitated  exactly  as  in  urine  analysis  (see 
page  111).  The  filtrate  from  the  mercury-acetone  precipitate  is 
received  into  a  dry  flask.  After  as  much  as  possible  of  the  solution 

FACTORS  FOR  CALCULATING  RESULTS  WIIEX  FILTRATE  EQUIVALENT  TO  5  c.c.  OF 
BLOOD  is  USED  FOR  DETERMINATION 


DETERMINATION   PERFORMED 

ACETONE     BODIES     CALCULATED     AS     GM. 
OF  ACETONE  PER  LITER  OF  BLOOD,   IN- 
DICATED   BY 

1  gm.  Precipitate 

1  c.c.  of  0.2  m.  KI 
Solution 

'i  otal  acetone   bodies 
Beta-hydroxybutyric  acid 
Acetone   plus  acetoacetic   ncid 

12.8 
13.2(14.0)* 
10.0 

0.1(31 
0.172(0.183)* 
0.130 

'These  factors  are  used  when  bela-oxybutyric  acid  is  determined  in  the  filtrate  from 
the  precipitated  acetone  and  acetoacetic  acid  as  described  above.  In  this  case  the 
amount  of  filtrate  taken  for  the  beta-acid  determination  is  equivalent  to  only  160/170 
of  5  c.c.  of  blood,  and  the  factor  must  be  correspondingly  increased. 


TESTS  FOR  ACIDOSIS  IN  BLOOD  79 

has  been  filtered  through,  and  before  any  wash  water  is  used,  160 
c.c.  of  the  filtrate  equivalent  to  160/170  x  5  c.c.  of  blood,  are 
placed  in  a  500  c.c.  Erlenmeyer  flask,  heated  to  boiling  under  a 
reflux  condenser,  and  5  c.c.  ,of  a  5  per  cent  potassium  dichromate 
solution  are  added  through  the  condenser.  The  rest  of  the  hy- 
droxybutyric  acid  determination  is  carried  out  as  described  for 
urine  from  the  point  where  the  dichromate  is  added. 

To  calculate  the  acetone  bodies  as  beta-hydroxybutyric  acid  in- 
stead of  as  acetone,  multiply  the  factors  by  1.793 ;  to  calculate  mo- 
lecular concentration,  divide  the  factors  by  58. 

Normal  blood  when  analyzed  as  described  for  total  acetone  bodies 
yields  only  1  or  2  mg.  of  precipitate,  equivalent  to  0.0013  to  0.026 
gm.  of  acetone  per  liter.  In  diabetes  as  much  as  2.5  gin.  of 
acetone  bodies  calculated  as  acetone  has  been  observed,  while  pa- 
tients under  ordinarily  good  control  show  0.1  to  0.4  gm. 

BIBLIOGRAPHY. 

Beddard,  Pembery,  and  Spriggs:     Jour.  Physiol.,  1908,  p.  37. 

Boothby  and  Peabody:     Arch.  Int.  Med.,  1914,  p.  497. 

Higgins:     Carnegie  Inst.  of  Washington,  1915,  pub.  203,  p.  168. 

Higgins  and  Means:     Jour.  Pharm.  and  Exper.  Therap.,  1915,  vol.  vii,  p.  1. 

Higgins,  Peabody,  and  Fitz:     Jour.  Med.  Research,  1916,  vol.  xxiv,  p.  263. 

Rowland  and  Marriott:     Bull.  Johns  Hopkins  Hosp.,  1916,  vol.  xxvii,  p. .63. 

Rowland  and  Marriott:     Am.  Jour.  Dis.  Child.,  May,  1916. 

Levy  and  Rowntree :     Arch.  Int.  Med.,  1916,  vol.  xvii,  p.  525. 

Levy,  Rowntree  and  Marriott:     Arch.  Int.  Med.,  1915,  vol.  xvi,  p.  389. 

Marriott:     Arch.  Int.  Med.,  1916,  vol.  xvii,  p.   840;   Jour.  Am.  Med.  Assn., 

1916,  vol.  Ixvi,  p.  1594. 

McClendon :     Jour.  Biol.  Chem.,  1916,  vol.  xxiv,  p.  519. 
McClendon  and  Magoon:     Jour.  Biol.  Chem.,  vol.  xxv,  p.  669. 
Peabody:    Am.  Jour.  Med.  Sc.,  1916,  vol.  cli,  p.  184. 
Plesch:     Ztschr.  f.  exper.  Path.  u.  Therap.,  1909,  vol.  vi,  p.  380. 
Stillman :     Am.  Jour.  Med.  Sc.,  1916,  vol.  cli,  p.  507. 
Van  Slyke:     Unpublished  data. 
Van  Slyke  and  Fitz:     Jour.  Biol.  Chem.,  1917,  vol.  xxxii,  No.  .3,  p.  495. 


PART  II. 
CHEMICAL  ANALYSIS  OF  URINE 

CHAPTER  XIV. 
TOTAL  NITROGEN. 

The  method  given  below  is  a  slight  modification  of  the  method 
given  by  Myers  and  Fine  which  in  turn  is  a  modification  of  the 
colorimetric  method  of  Folin  and  Farmer.  The  only  difference  in 
tcchnic  is  that  of  adding  peroxide  of  hydrogen  to  hasten  oxida- 
tion, which  considerably  shortens  the  time  of  making  the  test. 
In  the  method  of  Myers  and  Fine,  fully  fifteen  to  twenty  minutes 
is  required  to  complete  the  determination.  As  here  described,  the 
estimation  may  be  completed  in  from  five  to  ten  minutes.1 

For  the  determination,  an  amount  of  urine  sufficient  to  con- 
tain between  0.35  and  0.75  mgms.  nitrogen  is  required.  This  is 
usually  obtained  by  a  1  to  25  dilution  of  urine,  although  some- 
times a  dilution  of  1  to  10  is  sufficient,  as  indicated  by  a  low  spe- 
cific gravity.  Take  1  c.c.  of  urine  with  an  Ostwald-Folin  pipette 
and  dilute  to  25  c.c.  with  distilled  water  in  a  volumetric  flask. 
After  mixing  thoroughly,  place  1  c.c.  of  this  material  in  a  thin 
glass  test  tube,  to  which  is  added  5  to  7  drops  (0.1  c.c.)  of  con- 
centrated sulphuric  acid,  50  to  100  mgms.  of  potassium  sulphate, 
and  a  drop  of  copper  sulphate  (10%).  Now  boil  the  tube  by  hand 
(or  in  the  apparatus  as  shown  in  Fig.  17)  with  continued  shaking 
(if  boiled  in  apparatus  no  shaking  is  required)  until  the  con- 
tents become  dark  brown,  and  then,  while  the  tube  is  warm  (not 
hot),  add  a  drop  of  hydrogen  peroxide,  and  if  not  clear,  heat 
about  one  minute  until  clear.  It  is  this  part  of  the  technic  that 
we  have  modified ;  namely,  the  addition  of  peroxide  of  hydrogen. 
When  digestion  is  completed,  allow  the  tube  to  cool  for  one  min- 
ute and  then  wash  into  a  50  c.c.  volumetric  flask  or  accurate  50 

'Gradwohl  and  lilaivas:     Jour.  Am.   Med.  Assn.,   Sept.  9,   1916,  vol.  Lxvii,  p.  809. 


TOTAL   NITROGEN  81 

c.c.  graduate  (A)  with  about  35  c.c.  distilled  water.  Pipette  5  c.c. 
of  ammonium  sulphate  solution2  containing  1  mgm.  of  nitrogen 
per  5  c.c.  with  an  Ostwald-Folin  pipette  into  a  50  c.c.  volumetric 
flask  (B),  if  the  Hellige  colorimeter  is  to  be  employed,  and  add 
about  30  c.c.  of  distilled  water.  Dilute  10  c.c.  of  the  modified 
Nessler's  solution3  with  40  c.c.  of  distilled  water  just  previous 
to  use,  mix,  and  make  up  at  once  the  material  in  the  second  volu- 
metric flask  (standard)  to  volume  with  the  diluted  Nessler's  so- 
lution. The  "flask  (A),  unknown,  is  then  made  up  to  volume  with 
the  diluted  Nessler's  solution,  as  in  flask  B,  except  that  the  Ness- 
ler's solution  is  added  slowly  at  first  while  rotating  the  flask,  un- 
til the  alkali  of  the  Nessler's  solution  has  neutralized  the  sul- 
phuric acid.  Fill  a  dry,  glass-stoppered  wedge  for  the  Hellige 
colorimeter  with  the  standard  solution  (see  Plate  I  for  the  stand- 
ard color  of  1  mgm.  of  nitrogen)  and  adjust  in  the  colorimeter. 
Next  place  slightly  over  2  c.c.  of  the  unknown  solution  in  the 
empty  cup,  insert  in  the  colorimeter,  and  match  the  colors,  prefer- 
ably with  a  north  light.  The  amount  of  nitrogen  in  1/25  c.c.  of 
urine  maybe  ascertained  in  the  following  table  from  which  the 
nitrogen  content  of  the  specimen  of  urine  under  examination  may 
be  easily  computed. 

Since  the  figures  in  the  table  are  given  for  a  dilution  of  100  c.c., 
and  the  dilution  here  employed  is  50  c.c.,  the  result  obtained 
should  be  divided  by  2. 

Example. — The  twenty-four  hour  specimen  of  urine  contains 
1500  c.c.  Our  dilution  is  1  to  25.  Suppose  the  dilution  is  50. 
Reading  is  75,  which  is  equivalent  to  0.56  mgm.  per  dilution  of 
100  c.c.  Divide  by  2  equals  0.28  (our  dilution  is  50)  ;  multiply 
0.28  by  25  to  obtain  the  amount  in  1  c.c.  which  is  7  mgms.,  multi- 
plied by  1500  is  10,500  mgms.  or  10.5  grams  of  nitrogen  in  1500 
c.c.  urine. 


2This  standard  solution  is  prepared  by  dissolving  0.944  gm.  of  ammonium  sulphate  in 
distilled  water  and  making  up  to  1000  c.c. 

"For  one  liter  we  need  100  gms.  of  mercuric  iodide,  SO  gms.  of  potassium  iodide,  and 
200  gms.  of  potassium  hydroxide.  Place  the  mercuric  iodide  and  potassium  iodide,  both 
finely  powdered,  into  a  liter  volumetric  flask  and  add  about  400  c.c.  of  distilled  water. 
Now  dissolve  the  potassium  hydroxide  in  500  c.c.  distilled  water,  cool  thoroughly,  and 
add  with  constant  shaking  to  the  mixture  in  the  flask.  Then  make  up  to  one  liter  with 
water.  This  usually  becomes  perfectly  clear.  Keep  at  37°  C.  in  incubator  overnight  or 
until  the  yellowish  white  precipitate  which  may  settle  out  is  thoroughly  dissolved  and 
only  a  small  amount  of  the  dark  brownish  precipitate  remains.  The  solution  is  now 
ready  to  be  siphoned  off  and  used. 


82 


BLOOD   AND   URINE    CHEMISTRY 


TABLE  VI4 


ESTIMATION  OF  NITROGEN  WITH  THE  HELLIGE  COLORIMETER 


COLORI- 

NITROGEN 

COLORI- 

NITROGEN 

COLORI- 

NITROGEN 

METRIC 

MGMS.  PER 

METRIC 

MGMS.  PER 

METRIC 

MGMS.  PER 

READING 

DILUTION 

READING 

DILUTION 

READING 

DILUTION 

OF  100  C.C. 

OF  100  C.C. 

OF  100  C.C. 

20 

1.73 

40 

.31 

60 

0.89 

21 

1.71 

41 

.29 

61 

0.87 

22 

1.69 

42 

.27 

62 

0.85 

23 

1.67 

43 

.25 

63 

0.83 

24 

1.65 

44 

.23 

64 

0.81 

25 

1.62 

45 

1.20 

65 

0.78 

26 

1.60 

46 

1.18 

66 

0.76 

27 

.58 

47 

1.16 

67 

0.74 

28 

1.56 

48 

1.14 

68 

0.72 

29 

.54 

49 

1.12 

69 

0.70 

30 

1.52 

50 

1.10 

70 

0.67 

31 

1.50 

51 

1.08 

71 

0.65 

32 

1.48 

52 

1.06 

72 

0.63 

33 

1.46 

53 

1.04 

73 

0.61 

34 

1.44 

54 

1.02 

74 

0.59 

35 

1.41 

55 

0.99 

75 

0.56 

36 

1.39 

56 

0.97 

76 

0.54 

37 

1.37 

57 

0.95 

77 

0.52 

38 

1.35 

58 

0.93 

78 

0.50 

39 

1.33 

59 

0.91 

79 

0.48 

4Myers    and    Fine: 
York,    1915. 


Chemical    Composition    of    the    Blood    in    Health    and    Disease,    N( 


CHAPTER  XV. 

UREA. 

Dilute  the  urine  1  to  10  with  distilled  water.  Pipette  2  c.c.  of 
the  diluted  urine  into  a  test  tube  of  such  dimensions  that  it  will 
easily  slip  into  a  100  c.c.  graduated  cylinder  (no  lip),  add  about 
0.1  gm.  of  urease  and  incubate  the  contents  in  a  beaker  of  water 
at  50°  C.  for  one-half  hour.  At  the  end  of  this  time,  add  two 
drops  of  caprylic  alcohol  or  1  c.  c.  of  amylic  alcohol  to  prevent 
foaming  in  aeration. 

We  now  call  attention  to  the  manner  of  setting  up  the  glass- 
ware for  the  continuation  of  this  test  (see  Fig.  15).  The  chemistry 
of  this  estimation  is  about  as  follows :  the  enzyme  urease  converts 
urea  into  ammonium  carbonate.  The  ammonia  is  then  liberated 
by  aeration  in  the  presence  of  sodium  carbonate  in  excess  and  goes 
over  into  the  hydrochloric  acid  as  ammonium  chloride.  This 
can  be  determined  colorimetrically  by  the  use  of  Nessler's  re- 
agent. There  should  be  two  cylinders  for  each  sample  of  urine. 
If  more  than  one  urine  is  to  be  examined,  these  cylinders  may  be 
run  in  series,  two  for  each  test.  One  cylinder  is  graduated,  the 
other  nongraduated.  A  two-hole  rubber  stopper  is  placed  in  each 
cylinder.  Cylinder  1  (A- A')  is  graduated  and  is  connected  with 
the  suction.  Cylinder  2  (B-B')  is  nongraduated  and  is  connected 
with  the  acid  wash  bottle  (C).  If  more  than  one  urine  is 
under  examination,  cylinder  2  is  connected  with  the  short  con- 
nection of  the  other  graduated  cylinder,  etc.  This  acid  wash 
bottle  is  simply  a  bottle  containing  sulphuric  acid  (10%)  placed 
at  the  end  of  the  outfit  to  prevent  ammonia  from  the  air  from 
gaining  entrance  into  the  test.  Cylinder  1  (A- A'}  has  a  short 
tube  bent  at  right-angles  connected  to  the  suction  and  only  ex- 
tending in  the  cylinder  to  a  point  just  within  the  cylinder.  This  is 
tube  F-F'.  Tube  G-G'  extends  almost  to  the  bottom  of  cylinder  1. 
The  end  of  tube  G-G'  is  sealed  and  a  number  of  small  holes  are 
punched  in  its  side  with  platinum  wire  which  is  at  white  heat, 
provided  the  glass  is  only  moderately  hot.  Cylinder  2  has  a  right- 

83 


84  BLOOD   AND   URINE    CHEMISTRY 

angle  tube  extending  to  a  point  just  below  the  stopper  (Z>).  It  has 
another  tube  with  a  straight  open  end  dipping  into  the  test  tube 
(E)  and  running  out  to  be  connected  either  writh  the  acid  wash 
bottle  extension  or  with  another  series  of  cylinders  in  case  more 
than  one  urine  is  under  examination.  Into  the  100  c.c.  graduated 
cylinder  (cylinder  1)  add  20  c.c.  distilled  water  and  2  to  3  drops 
of  10%  hydrochloric  acid.  This  is  now  closed  and  -cylinder  2 
opened.  To  the  test  tube  containing  the  digested  urine  allow  an 
equal  volume  of  saturated  sodium  carbonate  to  slowly  run  down 
the  side  of  the  tube  under  the  urine.  Now  immediately  and  care- 
fully insert  the  tube  into  cylinder  2  and  immediately  close,  and 
then  carefully  and  tightly  seal  the  connection.  Start  the  suc- 
tion slowly  by  means  of  the  Chapman  pump  and  continue  slowly 
for  about  five  minutes,  and  then  increase  the  speed  of  the  suc- 
tion as  much  as  the  apparatus  will  stand.  Keep  up  the  aeration 
for  thirty  to  forty-five  minutes.  At  the  end  of  this  time  dis- 
connect the  cylinders,  and  cylinder  1  is  used  for  the  final  determi- 
nation. Remove  the  rubber  stopper  from  cylinder  1  and  wash 
down  the  tube  with  distilled  water  (2  to  3  c.c.). 

We  now  come  to  the  development  of  color.  Into  a  50  c.c. 
volumetric  flask,  pipette  5  c.c.  of  ammonium  sulphate  solution1 
containing  1  mgm.  of  nitrogen,  add  25  c.c.  distilled  water  and 
20  c.c.  Nessler's  solution2  diluted  1  to  5  (see  Plate  I  for  standard 
color  of  1  mgm.  of  nitrogen).  To  cylinder  1  containing  the  un- 
known in  the  form  of  ammonium  chloride,  add  from  10  to  25  c.c. 
of  diluted  Nessler's  solution  (1  to  5),  depending  upon  the  depth 
of  color,  and  dilute  to  50  c.c.,  100  c.c.,  etc.,  depending  upon  the 
color.  Make  the  colorimetrie  reading  at  once  and  compare  and 
compute  from  the  table  for  the  estimation  of  nitrogen  with  the 
Hellige  colorimeter  (see  page  82). 

The  result  will  be  for  0.2  c.c.  of  urine  (urine  diluted  1  to  10  for 
this  test  and  2  c.c.  of  diluted  urine  taken  for  the  determination 
which  is  equivalent  to  0.2  c.c.  urine). 

Example. — The  twenty-four  hour  specimens  contain  1500  c.c. ; 
dilution  is  100 ;  reading  is  58.  Equivalent  from  table  is  0.93  mgms. 
in  0.2  c.c.  urine.  Multiply  by  5  equals  4.65  mgms.  in  1  c.c.  urine ; 


]See   footnote  2,   page   81. 
2See  footnote  3,   page  81. 


UREA  85 

multiply  by  1500  equals  6975  mgms.  in  1500  c.c.  urine  or  6.975 
grams  Urea  N  in  1500  c.c.  urine. 

The  amount  of  urea  is  computed  by  multiplying  the  urea  ni- 
trogen by  the  factor  2.14. 

Example. — Urea  nitrogen  from  above  equals  6.975  grams,  mul- 
tiplied by  2.14,  equals  14.9265  grams  of  urea  in  1500  c.c.  urine. 

To  obtain  an  accurate  figure  for  the  urea  nitrogen  it  is  necessary 
to  make  a  correction  for  the  amount  of  ammonia  nitrogen  origi- 
nally present. 


CHAPTER  XVI. 
AMMONIA. 

An  amount  of  urine  sufficient  to  give  0.75  to  1.50  mgms.  of  am- 
monia nitrogen  should  be  employed.  With  normal  urines  2  c.c. 
will  generally  yield  the  desired  amount.  With  very  diluted  urines 
5  c.c.  may  be  required,  while  with  diabetic  urines,  rich  in 
ammonium  salts,  1  c.c.  may  be  excessive,  thus  requiring  dilution. 
Pipette  the  desired  amount  into  a  test  tube  about  200  mm.  in 
length  and  of  sufficient  diameter  so  that  it  will  slip  easily  into  a 
100  c.c.  graduated  cylinder  (no  lip). 

Aeration  is  carried  out  in  the  following  manner:  To  cylinder 
1  add  20  c.c.  of  distilled  water  and  2  to  3  drops  of  10%  hydro- 
chloric acid;  then  close  the  cylinder  and  connect  cylinder  2  (100 
c.c.  nongraduated)  to  cylinder  1  and  the  acid  wash  bottle  (sec 
Fig.  15).  In  the  test  tube  containing  the  urine  place  1  c.c.  of 
amylic  alcohol  or  2  to  3  drops  of  caprylic  alcohol  (to  prevent 
foaming),  and  allow  about  3  to  5  c.c.  of  saturated  sodium  car- 
bonate to  run  down  the  tube  gently  (under  the  urine)  so  that 
none  of  the  ammonia  will  escape.  Place  the  test  tube  in  the  100 
c.c.  cylinder  (nongraduated)  and  then  quickly  insert  the  stopper, 
being  careful  that  the  apparatus  is  properly  connected.  Start 
the  air  from  the  suction  slowly  through  the  apparatus,  increasing 
the  speed  gradually  so  that  at  the  end  of  about  5  minutes  the  air 
current  is  as  rapid  as  the  apparatus  will  stand.  Aeration  is  com- 
plete in  15  to  20  minutes.  Disconnect  the  apparatus  and  use  cyl- 
inder 1  for  the  final  determination.  Remove  the  rubber  stopper 
from  cylinder  1  and  wash  do~wn  the  tube  with  distilled  water  (2 
to  3  c.c.). 

We  now  develop  the  color.  In  a  50  c.c.  volumetric  flask,  pi- 
pette 5  c.c.  of  ammonium  sulphate  solution1  containing  1  mgm.  of 
nitrogen,  add  25  c.c.  distilled  water  and  20  c.c.  Nessler's  solu- 
tion2 diluted  1  to  5.  To  cylinder  1  (graduated)  containing  the  un- 


JSee  footnote   2,   page  81. 
!See  footnote  3,  page  81. 


AMMONIA  87 

known,  add  15  to  25  c.c.  of  diluted  Nessler's  solution  (1  to  5), 
depending  upon  the  depth  of  color,  and  dilute  to  50  c.c.,  100  c.c., 
etc.,  depending  upon  the  depth  of  color.  The  colorimetric  read- 
ing should  be  made  at  once.  Calculation  is  made  from  the  table 
already  given  (see  page  82),  and  the  results  recorded  as  am- 
monia nitrogen. 

Example. — Suppose  the  twenty-four  hour  specimen  contains 
1500  c.c.  urine ;  our  dilution  is  100,  reading  69. 

Suppose  2  c.c.  were  used  in  the  determination.  Equivalent 
from  table  is  0.70  mgm.  in  2  c.c.  urine.  Divide  by  2,  equals  0.35 
mgm.  in  1  c.c.  urine;  multiply  by  1500,  equals  525  mgm.  in  1500 
c.c.  urine  or  0.525  gram  of  ammonia  N. 


CHAPTER  XVII. 
TOTAL  ACIDITY. 

Folin's  Method. — In  the  quantitative  determination  of  the  acid- 
ity, the  twenty-four-hour  specimen  of  urine  is  used.  It  is  therefore 
necessary  to  use  a  preservative  in  order  to  avoid  decomposition. 

Place  25  c.c.  of  urine  in  an  Erlenmeyer  flask  of  250  c.c.  capacity. 
Add  about  15  grams  of  finely  powdered  potassium  oxalate  and 
1-2  drops  of  phenolphthalein  solution.*  Shake  the  mixture  vigor- 
ously for  about  a  minute  and  immediately  titrate  with  N/10  so- 
dium hydroxide  until  a  faint  but  permanent  pink  color  appears. 
Note  the  number  of  cubic  centimeters  used  and  calculate  the 
acidity. 

Calculation. — If  Y  represents  the  number  of  cubic  centimeters  of 
N/10  sodium  hydroxide  used  and  Y"  represents  the  volume  of  urine 
excreted  in  24  hours,  the  total  acidity  of  the  24-hour  urine  may  be 
calculated  by  the  following  proportion : 

25:Y::Y':X  (acidity  of  24-hour  urine  expressed  in  cubic  centi- 
meters of  N/10  sodium  hydroxide). 

Example. — Suppose  7.3  c.c.  of  N/10  sodium  hydroxide  were 
used,  then:  25:7.3 :  :1500:X  (assuming  that  the  volume  of  urine 
excreted  in  24  hours  was  1500  c.c.). 

25X  =  10950 

X  =  438    (acidity  of  24-hour  urine  expressed  in  cubic  centi- 
meters of  N/10  sodium  hydroxide) . 

Each  c.c.  of  N/10  sodium  hydroxide  contains  0.004  gram  of 
sodium  hydroxide,  and  this  is  equivalent  to  0.0063  gram  of  oxalic 
acid.  Therefore,  in  order  to  express  the  total  acidity  of  the  24-hour 
specimen  in  equivalent  grams  of  sodium  hydroxide,  multiply  X  by 
0.004.  If  it  is  desired  to  express  the  total  acidity  in  grams  of  oxalic 
acid,  multiply  X  by  0.0063. 

Example. — 438  times  0.004  =  1.752  grams  of  sodium  hydroxide 
in  24-hour  specimen. 

"This  is  prepared  by  dissolving  1  gram  of  phenolphthalein  in   100  c.c.  of  95%  alcohol. 

88 


TOTAL  ACIDITY  89 

438  times  0.0063  =  2.7594  grams  of  oxalic  acid  in  24-hour  spec- 
imen. 

The  acidity  of  the  urine  expressed  in  cubic  centimeters  of  N/10 
sodium  hydroxide  (alkali)  required  to  neutralize  the  24-hour  out- 
put varies  from  200  to  500  with  an  average  of  about  350.  The 
acidity  depends  largely  upon  the  diet  of  the  individual. 

Conditions  in  which  the  acidity  of  the  urine  may  be  increased : 
Fasting 
Acidosis 

Cardio-renal  and  other  disorders. 
Administration  of  mineral  acids,  acid  phosphates,  or  ben- 

zoates. 

It  is  much  more  difficult  to  increase  than  decrease  the  acidity 
of  urine. 


CHAPTER,  XVIII. 
URIC  ACID. 

Into  a  15  c.c.  conical  centrifuge  tube  pipette  2  c.e.  of  urine, 
and  add  15  drops  of  ammoniacal-silver-magnesium  mixture.1  In- 
vert the  centrifuge  tube  in  order  to  mix  the  contents  and  then  place 
the  tube  in  the  refrigerator  for  about  ten  minutes,  after  which 
centrifuge  the  tube  for  from  3  to  5  minutes,  and  then  pour  off  the 
supernatant  fluid  by  inverting  the  tube.  (The  precipitate  will 
remain  at  the  bottom.)  Wipe  the  lip  of  the  centrifuge  tube  with  fil- 
ter paper.  Volatilize  the  ammonia  by  attaching  the  mouth  of  the 
tube  to  the  suction.  We  arc  now  ready  for  the  development  of 
color,  and  the  reading.  As  previously  mentioned,  we  must  again 
urge  the  beginner  to  work  as  fast  as  possible  as  the  color  may  fade 
or  turbidity  may  develop. 

Prepare  a  100  c.c.  graduated  cylinder  for  the  unknown  and  a 
50  c.c.  volumetric  flask  for  the  standard  solution.2  Then  pipette 
5  c.c.  of  uric  acid  standard  (5  c.c.  equals  1  mgm.  of  uric  acid) 
into  the  50  c.c.  volumetric  flask.  To  the  standard  solution  add 
2  drops  of  a  5%  solution  of  potassium  cyanide,  2  c.c.  of  Folin- 
Macallum3  reagent,  20  c.c.  of  saturated  sodium  carbonate,  and  in 
one  minute,  add  water  to  the  50  c.c.  mark.  (See  Plate  I  for  the 
standard  uric  acid  wedge.)  To  the  precipitate  in  the  centrifuge 
(which  is  free  from  ammonia)  add  2  drops  of  a  5%  solution  of 


'For  the  preparation  o 
nitrate  solution,  30  c.c.  o 
turbidity  which  may  dev 
is  made  as  follows:    diss 
chloride  in  280  c.c.  of  di 
2For   the   preparation 
talline  hydrogen   disodiu 
c.c.   to  300  c.c.   distilled 

ammoniacal-silver-magnesium  mixture,  mix  70  c.c.   of  3%  silver 
magnesium  mixture,  and  100  c.c.  of  concentrated  ammonia.     Any 
op  is  removed  by  nitration.      The  magnesia  mixture  alluded   to 
ve  35  grams  of  magnesium  sulphate  and  70  grams  of  ammonium 
lied  water  and  then  add  140  c.c.  of  concentrated  ammonia, 
f   uric   acid    standard    solution,    dissolve   9    grams   of   pure    crys- 
phosphate   and    1    gm.    of   dihydrogen   sodium    phosphate   in    200 
water.     Filter  and  make  up  to  about   500  c.c.   with  hot  -distilled 

baum)  suspended  in  a  few  cubic  centimeters  of  water  in  a  liter  flask.  Agitate  until 
completely  dissolved,  and  add  at  once  exactly  1.4  c.c.  glacial  acetic  acid.  Make  up  to 
one  liter,  mix  and  add  5  c.c.  chloroform.  Five  c.c.  of  this  solution  is  equivalent  to 
1  mgm.  of  uric  acid.  This  solution  should  be  freshly  prepared  every  two  months.  Be- 
fore weighing  out  the  200  mgms.  of  uric  acid,  it  is  well  to  dry  the  quantity  from  which 
the  measure  is  to  be  made  in  a  drying  oven  at  100°  C.  overnight. 

•For  the  preparation  of  the  Folin-Macallum  reagent,  boil  100  gms.  of  sodium  tungstate, 
20  c.c.  of  concentrated  hydrochloric  acid,  and  30  c.c.  of  85%  phosphoric  acid  in  750_  c.c. 
for  two  hours  and  then  make  up  to  1000  c.c.  with  distilled  water.  In  boiling  it  is 
well  to  have  a  funnel  over  the  flask  so  as  to  prevent  undue  evaporation. 

90 


URIC    ACID  91 

potassium  cyanide  and  shake  the  tube  so  as  to  dissolve  the  pre- 
cipitate. Add  2  c.c.  of  Folin-Macallum  reagent.  Wash  the  con- 
tents of  the  centrifuge  tube  into  the  100  c.c.  graduate  with  from 
15  to  20  c.c.  saturated  sodium  carbonate.  If  the  color  is  well 
developed,  more  carbonate  is  used;  i.  e.,  use  the  20  c.c.  amount 
when  the  color  is  stronger  than  the  standard,  and  the  15  c.c. 
when  it  is  fainter.  The  fundamental  principle  of  these  dilutions 
in  microchemical  work  is  to  have  the  unknown  solution  weaker 
in  color  than  the  standard.  A  space  of  time  of  from  forty  to 
sixty  seconds  should  be  allowed  to  elapse  before  determining 
whether  we  are  going  to  dilute  to  50  c.c.  or  100  c.c.  Dilute  with 
distilled  water  to  50  c.c.,  100  c.c.  depending  upon  the  depth  of 
color  obtained.  The  table  for  estimation  of  uric  acid  with  the 
Hellige  colorimeter  gives  the  data  for  working  out  the  amount  of 
uric  acid  present.  (See  page  40  for  uric  acid  table.) 

Example  1. — Suppose  the  volume  of  urine  for  24  hours  is  1500 
c.c.  Dilution  is  100  c.c.  Reading  is  60.  Equivalent  from  table  is 
0.88  mgin.  in  2  c.c.  urine.  Divide  by  2,  equals  0.44  mgm.  in  1 
c.c.  urine;  multiply  by  1500  equals  660  mgms.  in  1500  c.c.  urine 
or  0.66  gram  in  1500  c.c.  Since  uric  acid  contains  33%  nitrogen; 
the  amount  of  uric  acid  nitrogen  may  easily  be  computed  from 
this  factor  when  it  is  desired. 

Example  2.— Uric  acid  (above)  equals  0.66  gram;  33%  of  0.66 
gram  equals  0.2178  gram  of  uric  acid  nitrogen. 


CHAPTER  XIX. 
CREATININE. 

Into  a  100  c.c.  volumetric  flask  or  cylinder,  pipette  2  c.c.  of 
urine.  Add  3  c.c.  of  saturated  picric  acid  and  1  c.c.  of  10%  so- 
dium hydroxide.  Mix  the  solution  thoroughly  and  allow  to  stand 
for  five  minutes.  This  is  done  to  allow  for  the  development  of 
color.  At  the  end  of  this  time  make  up  the  mixture  to  100  c.c. 
with  tap  water,  thoroughly  mix  and  read  several  times  in  the 
colorimeter,  using  normal  bichromate1  as  a  standard.  The  amount 
of  creatinine  in  2  c.c.  of  urine  is  obtained  by  ascertaining  the 
value  of  the  colorimetric  reading  in  the  Table  VII  for  the  estima- 
tion of  creatinine.  If  the  concentration  of  creatinine  in  the  urine 
is  not  such  that  the  readings  from  the  colorimeter  fall  within  the 


TABLE  VII2 


ESTIMATION  OF  CREATININE  WITH  THE  HELLIGE  COLORIMETEK 


COLORI- 

CREATININE 

COLORI- 

CHEATININE 

COLORI- 

CREATININE 

METRIC 

MGMS.  PER 

METRIC 

MGMS     PER 

METRIC 

MGMS.  PER 

READING 

DILUTION 

READING 

DILUTION 

READING 

DILUTION 

OF    100   C.C. 

OF    100    C.C. 

OF  100  C.C. 

20 

2.46 

35 

2.13 

51 

.78 

21 

2.43 

36 

2.10 

52 

.76 

22 

2.41 

37 

2.08 

53 

.74 

23 

2.39 

38 

2.06 

54 

.72 

24 

2.37 

39 

2.04 

55 

.69 

25 

2.35 

40 

2.02 

56 

.67 

26 

2.33 

41 

1.99 

57 

.65 

27 

2.30 

42 

1.97 

58 

.62 

28 

2.28 

43 

1.95 

59 

.60 

29 

2.29 

44 

1.92 

60 

.57 

30 

2.24 

45 

1.90 

61 

.54 

31 

2.21 

46 

1.88 

62 

.51 

32 

2.19 

48 

1.85 

63 

.48 

33 

2.17 

49 

1.83 

64 

.45 

34 

2.15 

50 

1.81 

65 

.42 

1Normal  bichromate  is  prepared  by  dissolving  24.55  grams  of  potassium  bichromate  in 
distilled  water,  and  making  up  to  500  c.c. 

2Myers  and  Fine:  Chemical  Composition  of  the  Blood  in  Health  and  Disease,  New 
York,  1915. 

92 


CREATININE  93 

figures  of  the  table,  repeat  the  test,  using  larger  or  smaller  amounts 
of  urine  as  the  case  may  be. 

Example  1. — Volume  of  urine  in  twenty-four  hour  specimen  is 
1500  c.c.  Heading  on  colorimeter  is  58.  Equivalent  on  table  is 
1.62  mgms.  in  2  c.c.  urine.  Divide  by  2  equals  0.81  mgm.  for 
1  c.c.;  multiply  by  1500,  equals  1215  mgms.  or  1.215  grams  in 
1500  c.c.  urine. 

Creatinine  contains  37.2%  of  nitrogen  and  if  the  creatinine 
nitrogen  is  desired  it  may  easily  be  calculated  from  this  factor. 

Example  2. — 37.2%  of  1.215  grams  equals  0.45198  gram  of  creat- 
inine N. 


CHAPTER  XX. 
CREATINE. 

Place  2  c.c.  of  urine  in  a  medium-sized  test  tube  and  add  2  c.c. 
of  normal  hydrochloric  acid  and  a  very  little  powdered  metallic  lead. 
Boil  the  contents  of  the  tube  nearly  to  dryness  over  a  free  flame, 
then  wash  with  as  little  water  as  possible  through  a  small  cotton  or 
glass  wool  filter  into  a  100  c.c.  volumetric  flask.  This  removes 
the  metallic  lead  which  also  reacts  with  the  picric  acid  and  alkali. 
To  the  volumetric  flask  add  3  c.c.  of  saturated  picric  acid  and  2  c.c. 
of  10%  sodium  hydroxide.  Mix  the  solution  thoroughly  and  allow 
to  stand  for  five  minutes.  At  the  end  of  this  time,  make  up  the 
mixture  to  100  c.c.  with  tap  water,  thoroughly  mix  and  read 
several  times  in  the  colorimeter,  using  the  same  standard  (normal 
bichromate)  and  table  as  for  creatinine.  The  result  obtained  is 
the  total  creatinine.  The  difference  between  the  preformed  and 
the  total  creatinine  gives  the  creatine  in  terms  of  creatinine.  By 
multiplying  this  value  by  1.16  the  weight  of  the  creatine  may  be 
obtained. 

Example. — Volume  of  urine  in  twenty-four  hour  specimen  is 
1500  c.c.  Reading  on  colorimeter  is  45.  Equivalent  on  table  is 
1.90  mgms.  in  2  c.c.  urine.  Divide  by  2  equals  0.95  mgms.  in  1  c.c. 
urine;  multiply  by  1500,  equals  1.425  grams  total  creatinine  in 
1500  c.c.,  viz. : 

Reading  =  45. 

Table  equivalent  =  1.90  +  2  =  0.95  in  1  c.c.  x  1500  =  1.425  grams  = 
total  creatinine  in  1500  c.c. 

Total  creatinine  1.425  grams  in  1500  c.c.  urine  (preformed  creat- 
inine, 1.215  grams  in  1500  c.c.  urine)  creatine  in  terms  of  creat- 
inine equal  0.210  gram  in  1500  c.c.  urine.  Multiply  0.210  by 
the  (above)  factor  1.16  which  equals  0.2436  gram  of  creatine  in 
1500  c.c.  of  urine. 


CHAPTER  XXI. 
PHENOLSULPHONEPHTHALEIN 

The  phenolsulphonephthalein  test  for  renal  function  was  de- 
vised by  Rowntree  and  Geraghty  and  depends  upon  the  injection 
into  the  tissues  of  a  dyestuff  which  is  eliminated  rather  rapidly 
by  the  normal  kidney,  and  can  be  estimated  quantitatively  in  the 
urine.  Phenolsulphonephthalein  (the  dyestuff)  is  noiiirritant  to 
the  body  either  when  taken  by  mouth  or  when  injected  into  the 
tissues.  It,  therefore,  does  no  harm  to  an  already  weakened  kid- 
ney. The  patient  who  is  to  receive  the  injection  is  given  300  to 
400  c.c.  of  water  about  one-half  hour  previously,  in  order  to  as- 
sure a  free  flow  of  urine. 

Procedure. — Inject  1  c.c.  of  a  solution1  containing  6  mgms.  of 
phenolsulphonephthalein  intramuscularly  in  the  lumbar  region  (the 
time  of  the  injection  being  noted) .  Allow  ten  minutes  for  the  begin- 
ning of  the  excretion  of  the  drug.  Now  collect  the  urine  for  two 
hours,  each  hour  being  kept  in  separate  bottles,  labelled  1st  hour 
and  2nd  hour.  In  other  words,  after  one  hour  and  ten  minutes, 
the  urine  is  collected  in  bottle  number  1,  and  in  two  hours  and 
ten  minutes  the  second  specimen  of  urine  is  collected  in  bottle 
number  2.  In  patients  with  obstruction  to  the  flow  of  urine  from 
the  bladder,  the  retention  catheter  is  stoppered  and  the  urine 
drawn  off  at  the  end  of  each  hour.  Other  patients  may  simply  be 
allowed  to  urinate  at  hourly  periods. 

One  c.c.  ampules  (Fig.  28)  containing  6  mgms.  of  the  dye  can 
be  purchased  at  any  reliable  drug  concern.  Fig.  29  shows  a  care- 
fully graduated  syringe  for  making  this  injection. 

To  bottle  number  1,  add  10  c.c.  of  a  10%  solution  of  sodium  hy- 
droxide and  wash  the  contents  into  a  1000  c.c.  graduate  wifti  tap 
water.  Then  dilute  to  1000  c.c.,  500  c.c.,  etc.,  depending  upon  the 
amount  of  dye  excreted;  i.e.,  the  more  dye  excreted,  the  greater 

lThis  solution  is  prepared  by  adding  0.6  grams  of  phenolsulphonephthalein  and 
0.84  c.c.  of  2/N  sodium  hydroxide  to  enough  0.75%  sodium  chloride  solution  to  make 
100  c.c.  This  gives  the  monosodium  or  acid  salt  which  is  slightly  irritant  locally  when 
injected.  It  is  necessary  to  add  2  to  3  drops  more  2/N  sodium  hydroxide  which  changes 
the  color  to  a  bordeaux  red.  This  preparation  is  nonirritant. 

95 


96 


BLOOD   AND    URINE    CHEMISTRY 


the  dilution.  It  is  then  read  in  the  colorimeter  with  phenolsul- 
phonephthalein  as  a  standard,  and  the  calculation  made  from  the 
Table  VIII.  (See  Plate  I  for  the  color  of  the  standard  phenol- 
sulphonephthalein  wedge. ) 

To  bottle  number  2  also  add  10  c.c.  of  10%  solution  of  sodium 
hydroxide  and  wash  the  contents  into  a  1000  c.c.  graduate  with 


Fig.   28.- 


Fig.  29.- 
injecti 


Graduated  syringe  used   for  the 
n   of  phenolsulphonephthalein. 


tap  water.  Then  dilute  to  1000  c.c.,  500  c.c.,  etc.,  depending  upon 
the  amount  of  dye  excreted.  Then  read  in  the  colorimeter  and 
make  the  calculation  as  above.  The  amount  of  dye  excreted  in 
both  hours  is  added  together  and  recorded.2 


2Standard  phenolsulphonephthalein  is  prepared  by  adi 
hydroxide  to  exactly  1  c.c.  of  a  solution  of  phenolsulphonc 
rngms.  of  the  dye  and  making  up  to  exactly  one  liter. 


ig     10     c.c.     of     \0'/r 
ithalein   solution  cont 


sodium 
ning  6 


PHENOLSULPHOXEPIITHALEIN 


Example. — First  hour  dilution  was  1000  c.c.,  reading  56,  equiva- 
lent on  table  to  45%  excretion  first  hour.  Second  hour  dilution 
was  500  c.c.,  reading  40,  equivalent  on  table  to  62%,  which  is 
divided  by  two  because  the  dilution  was  to  500  c.c.  and  the  table 
requirement  is  for  a  dilution  of  1000  c.c.  The  second  hour  is 
31  per  cent.  The  final  report  is  as  follows : 


1st  hour 
2nd  hour 


45  per  cent 
31  per  cent 


Total  76  per  cent   (normal) 

TABLE  VIII3 


ESTIMATION  OF  PHENOLSULPHONEPHTHALEIN 


PHENOL- 

PHENOL- 

PHENOL- 

PHENOL- 

SUL- 

SUL- 

SUL- 

8UL- 

PHONE- 

PHONE- 

PHONE- 

PHONE- 

COLORI- 

PHTHAL- 

COLORI- 

PHTHAL- 

COLORI- 

PHTHAL- 

COLORI- 

PHTHAL- 

METRIC 

EIN 

METRIC 

EIN 

METRIC 

EIN 

METRIC 

EIN 

READ- 

OUTPUT 

READ- 

OUTPUT 

READ- 

OUTPUT 

READ- 

OUTPUT 

ING 

PER  DILU- 

ING 

PER  DILU- 

ING 

PER  DILU- 

ING 

PER  DILU- 

TION OF 

TION  OF 

TION  OF 

TION  OF 

1000  C.C. 

1000  C.C. 

1000  C.C. 

1000  C.C. 

Per  Cent 

Per  Cent 

Per  Cent 

Per  Cent 

10 

94 

30 

73 

50 

52 

70 

30 

11 

93 

31 

72 

51 

50 

71 

29 

12 

92 

32 

71 

52 

49 

72 

28 

13 

91 

33 

70 

53 

48 

73 

27 

14 

90 

34 

69 

54 

47 

74 

26 

15 

89 

35 

68 

55 

46 

75 

24 

16 

88 

36 

67 

56 

45 

76 

23 

17 

87 

37 

66 

57 

44 

77 

22 

18 

86 

38 

65 

58 

43 

78 

21 

19 

85 

39 

64 

59 

42 

79 

20 

20 

84 

40 

62 

60 

41 

80 

19 

21 

82 

41 

61 

61 

40 

81 

18 

22 

81 

42 

.  60 

62 

39 

82 

17 

23 

80 

43 

59 

63 

37 

83 

16 

24 

79 

44 

58 

64 

36 

84 

15 

25 

78 

45 

57 

65 

35 

85 

14 

26 

77 

46 

56 

66 

34 

86 

12 

27 

76 

47 

55 

67 

33 

87 

-  11 

28 

75 

48 

54 

68 

32 

88 

10 

29 

74 

49 

53 

69 

,  31 

89 

9 

"Myers   and    Fine:      Chemical    Composition    of   the    Blood    in    Health    and    Disease,    New 
York,   1915. 

Indigo- Carmin  Test  for  Kidney  Efficiency. — This  is  the  so- 
called  indigo-carmin  test  of  Folkner  and  Joseph.     This  substance 


98  BLOOD   AND   URINE    CHEMISTRY 

comes  in  tablet  form  and  is  manufactured  by  Bruckner,  Lampe  & 
Company.  The  tablets  are  blue  and  are  soluble  in  water.  The 
solution  is  injected  intramuscularly.  These  two  observers  found 
that  the  elimination  of  indigo-carmin  begins  about  eight  to  ten 
minutes  after  its  injection.  The  original  method  of  Folkner  and 
Joseph  is  to  examine  the  bladder  through  a  cystoscope  and  observe 
the  first  appearance  of  the  blue  color  in  the  bladder.  This  is  in 
other  words  a  method  of  chromo-cystoscopy.  The  test  was  modi- 
fied by  Kapsemar  and  is  perhaps  better  carried  according  to  his 
technic :  both  ureters  are  catheterized  and  the  time  of  appearance 
of  the  blue  color  is  observed  from  either  kidney  in  this  way.  The 
indigo-carmin  is  mixed  in  the  following  manner:  five  tablets  are 
boiled  in  100  c.c.  of  distilled  water  for  three  to  four  hours.  This 
is  enough  material  for  five  injections.  Preserve  in  a  well  stoppered 
bottle  until  ready  for  use.  Inject  20  c.c.  for  a  test,  boiling  it  be- 
fore the  test  and  injecting  it  while  warm.  The  injection  is  made 
into  the  relaxed  gluteal  muscles. 

This  is  a  good  test  as  a  preliminary  measure,  but  is  only  useful 
when  positive  results  are  obtained.  If  the  blue  color  is  specifically 
delayed  on  either  side,  the  result  may  be  interpreted  as  an  indica- 
tion of  local  kidney  deficiency.  Nevertheless,  it  must  be  mentioned 
that  there  are  numerous  cases  in  which  there  has  been  well  marked 
kidney  insufficiency  and  yet  the  blue  color  appeared  promptly  on 
both  sides. 

Cryoscopy  of  Blood  and  Urine. — It  was  Koranyi  who  first 
opened  up  the  path  of  cryoscopy  in  connection  with  kidney  diag- 
nosis. The  estimation  of  the  freezing  point  of  human  blood  was 
first  used.  It  must  be  assumed  that  the  freezing  point  in  healthy 
human  blood  is  a  constant  factor.  Upon  this  point,  Koranyi  con- 
structed the  following  principle :  if  you  have  normal  kidneys,  you 
have  a  constant  freezing  point  for  blood  from  such  people.  Let 
us  assume  0.56°C.  as  the  freezing  point  of  normal  human  blood. 
The  ease  of  freezing  is  in  proportion  to  the  number  of  molecules  in 
the  blood.  In  other  words,  the  more  molecules  present,  the  more 
difficult  it  is  to  freeze.  .  In  diseases  of  the  kidney  we  have  more 
molecules  in  the  blood,  ergo  the  freezing  point  of  blood  from  a 
patient  with  diseased  kidneys  is  appreciably  lowered.  This  is 
theoretically  a  good  rule  but  there  are  so  many  exceptions  that  it 
is  difficult  to  use  this  principle  in  actual  practice.  There  are  some 


PHENOLSULPHONEPHTHALEIN  99 

kidney  diseases  in  which,  while  the  blood  ought  to  be  concentrated, 
there  ensues  such  a  rapid  thinning  out  that  its  freezing  point  may 
be  normal.  The  use  of  blood  cryoscopy  in  the  diagnosis  of  kidney 
disease  has  been  abandoned  by  nearly  every  one  excepting  per- 
haps Kuemmel,  of  Hamburg,  who  according  to  our  latest  informa- 
tion continues  to  use  it.  The  technic  is  not  difficult  but  there  are 
many  sources  of  mechanical  error  in  the  hands  of  the  unskilled. 
Of  more  importance  in  practical  work  is  the  cryoscopy  of  urine. 
Cryoscopy  is  a  method  of  determination  of  the  number  of  molecules 
present.  If  you  take  the  urine  from  two  sides,  one  healthy  and 
one  diseased,  you  will  find  on  the  diseased  side  a  urine  with  a  de- 
creased number  of  molecules  for  the  reason  that  the  kidney  is  not 
functionating  as  well  as  it  should  in  conditions  of  health.  It  is, 
therefore,  throwing  out  less  material,  hence  a  lessened  number  of 
molecules,  hence  freezing  of  this  urine  is  not  difficult;  therefore, 
the  freezing  point  of  urine  of  this  kind  is  higher  than  urine  from  a 
healthy  kidney.  For  instance,  if  the  left  kidney  has  a  high  freez- 
ing point,  the  right  kidney  a  lower  freezing  point,  then  it  is  the 
left  kidney  that  is  diseased.  We  express  the  mean  average  stand- 
ard freezing  point  of  urine  by  the  large  capital  Greek  letter  Delta. 
The  freezing  point  of  urine  varies  ordinarily  between  -1.3°  and 
-2.3°  C.,  the  freezing  point  of  water  being  taken  as  0°  C.  A  is  sub- 
ject to  very  wide  variations,  therefore,  its  interpretation  must  be 
taken  up  with  some  discrimination.  A  copious  drinking  of  water 
will  cause  the  A  to  have  as  high  a  value  as  -0.2°  C.  A  diet  con- 
taining much  salt  and  deficient  in  fluids  will  lower  it  to  -0.3°  C. 
Marked  variations  are  of  importance  in  reading  disease  of  the  kid- 
ney with  cryoscopy  findings.  A  concrete  example  of  the  reading  of 
cryoscopy  might  be  given  as  follows  : 

Example  1. — 

Left  Kidney  Right  Kidney 

Clear  Pus 

A  =  -2.46  C.  A  =  -1.03  C. 
Diagnosis. — Pyuria  with  disturbance  of  the  right  kidney  function. 
Example  2. — 

Left  Kidney  Right  Kidney 

Clear  Pus 

A  =  -2.46  C.  A  =  -2.11 


100  BLOOD   AND   URINE    CHEMISTRY 

Diagnosis. — Pyuria,  with  disease  of  the  right  kidney,  but  the  dif- 
ference in  the  freezing  points  is  so  slight  that  it  is  not  possible  to 
absolutely  say  that  the  function  of  the  right  kidney  is  materially 
disturbed. 

Cryoscopy  is  best  carried  out  by  means  of  the  Beckman  appa- 
ratus. This  consists  of  a  heavy  battery  jar  with  a  metal  cover  with 
a  circular  hole  in  the  center.  This  jar  holds  the  freezing  mixture  by 
means  of  which  the  temperature  of  the  urine  is  lowered  and 
estimated.  A  large  glass  tube  in  the  center  serves  as  an  air-jacket 
and  is  inserted  through  the  central  hole.  Within  this  is  received 
the  small  tube  containing  the  urine  to  be  tested.  A  thermometer 
graduated  in  hundredths  of  a  degree  is  introduced  into  the  inner 
tube  and  is  held  in  place  by  means  of  a  cork  so  that  the  mercury 
bulb  is  immersed  in  the  fluid  under  examination  but  does  not  come 
in  contact  with  the  glass  surface  anywhere.  A  small  stirrer  drops 
into  the  fluid  and  is  used  to  stir  it  while  it  is  being  frozen.  Another 
stirrer  mixes  up  the  ice  and  rock  salt  mixture.  Rock  salt  one  part 
and  ice  3  parts,  makes  a  good  freezing  mixture.  Make  the  test  as 
follows:  produce  a  temperature  not  lower  than  3°  C.  in  the  freez- 
ing mixture.  Introduce  the  urine  to  be  tested  in  the  small  test 
tube,  stir  both  stirrers  so  as  to  equalize  the  temperature  slowly  and 
watch  the  column  of  mercury  in  the  thermometer  which  dips  into 
the  urine.  This  mercury  will  fall  slowly  as  freezing  occurs.  You 
will  then  observe  a  sudden  jump  in  the  mercury  column  after  it 
falls.  The  point  that  it  rises  to  after  this  jump  is  the  freezing  point. 


CHAPTER  XXII. 
CHLORIDES. 

Pipette  5  c.c.  of  urine  into  a  small  evaporating  dish  and  add 
about  20  c.c.  distilled  water.  Precipitate  the  chlorides  by  the  ad- 
dition of  exactly  10  c.c.  of  standard  silver  nitrate  solution1  and 
add  2  c.c.  of  the  indicator.2  Run  in  from  a  burette  standard  am- 
monium thiocyanate  until  the  first  trace  of  yellow  shows  through- 
out the  mixture  on  stirring.  By  subtracting  the  number  of  cubic 
centimeters  required  to  exactly  precipitate  the  chlorides  from  ten 
(silver  nitrate  added)  and  multiplying  by  0.01,  the  grams  of 
sodium  chloride  in  5  c.c.  of  urine  are  obtained.  From  this  the 
total  chloride  output  for  the  twenty-four  hour  specimen  may  be 
computed.  The  twenty-four  hour  specimen  contains  1500  c.c. 
urine. 

Example. — 6.2  c.c.  standard  ammonium  thiocyanate3  used  sub- 
tracted from  10  equals  3.8  c.c.  of  silver  nitrate  (standard)  actually 
required.  Multiply  this  by  0.01  gram  (1  c.c.  of  standard  silver 
nitrate  equals  0.01  gram  of  sodium  chloride),  equals  0.038  gram  of 
sodium  chlorides  in  5  c.c.  urine.  In  1500  c.c.  urine  there  will  then 
be  300  times  0.038  gram  of  sodium  chloride  or  11.4  grams  of  sodium 
chloride  in  1500  c.c.  of  urine. 


JFor  the  preparation  of  the  standard  silver  nitrate  solution,  dissolve  29.06  grams  of 
silver  nitrate  in  distilled  water  and  make  up  to  one  liter  with  distilled  -water.  Each 
cubic  centimeter  of  such  a  solution  is  equivalent  to  0.01  gram  of  sodium  chloride. 

:For  the  preparation  of  the  indicator,  dissolve  100  grams  of  crystalline  ferric  am- 
monium sulphate  in  100  c.c.  of  25  per  cent  nitric  acid. 

3For  the  preparation  of  standard  ammonium  thiocyanate,  dissolve  about  13  grams  of 
ammonium  thiocyanate  in  800  c.c.  distilled  water.  .Titrate  this  solution  against  the 
above  standard  silver  nitrate  solution,  thus  ascertaining  the  amount  of  water  which  must 
be  added  to  the  solution  to  make  it  equivalent  to  the  silver  nitrate  solution. 


101 


CHAPTER  XXIII. 

GENERAL  ANALYSIS. 

Urine. 

Volume. — This  is  easily  measured  in  one  liter  graduates.  The 
volume  of  urine  excreted  by  normal  individuals  is  influenced 
greatly  by  the  diet,  particularly  by  the  volume  of  fluid  ingested. 
The  normal  figures  fall  within  from  1000  c.c.  to  1200  e.c. 

Pathological  conditions  which  cause  increase  in  the  output  of 
urine,  may  be  enumerated  as  follows : 

1.  Diabetes  mellitus. 

2.  Diabetes  insipidus. 

3.  Certain  diseases  of  the  nervous  system. 

4.  Contracted  kidney. 

5.  Amyloid  degeneration  of  the  kidney. 

6.  Convalescence  from  acute  diseases. 

Many  drugs,  such  as  calomel,  digitalis,  acetates,  and  salicylates, 
also  cause  an  increase  in  the  output  of  urine. 

Pathological  conditions  which  cause  decrease  in  output  of  the 
urine : 

1.  Acute  nephritis. 

2.  Diseases  of  the  heart. 

3.  Diseases  of  the  lungs. 

4.  Fevers. 
-5.  Diarrhea. 

6.  Vomiting. 

Color. — The  color  of  normal  urine  varies  from  a  very  pale  yel- 
low to  a  reddish  yellow.  The  nature  and  origin  of  the  chief 
variations  in  the  urinary  color  are  set  forth  in  tabular  form  by 
Halliburton,  as  shown  in  Table  IX. 

Transparency. — Normal  urine  is  ordinarily  perfectly  clear.  On 
standing  a  few  hours  a  cloud  (nubecula)  consisting  of  mucus 
threads,  epithelial  cells,  etc.,  forms.  After  a  hearty  meal  the  urine 
is  generally  turbid,  due  to  the  precipitation  of  phosphates,  and 

102 


2  3 

PLATE   III. — URINE   COLOR    REACTIONS. 


1.  Showing  Indican   Reaction. 

2.  Showing   Benzidine    Test   for   Blood. 

3.  Showing   Acetone    Reaction. 

4.  Showing  Diacetic  Acid   Reaction. 


GENERAL   ANALYSIS 


103 


TABLE  IX. 


COLOR. 


Nearly  colorless 


Dark    yellow    to    brown- 
red 


Milky 

Orange 

Eed  or  reddish 


CAUSE  OF  COLORATION. 


Brown  to  brown-black 


Greenish-yellow,  greenish - 
brown  approaching 
black 

Dirty  green*  or  blue 


Brown  -  yellow  to  red- 
brown,  becoming  blood- 
red  upon  adding  alka- 
lies. 


Dilution  or  diminution  of 
normal  pigments 


Increase  of  normal,  or 
occurrence  of  patho- 
logical pigments,  con- 
centrated urine 

Fat  globules 
Pus  corpuscles 


Excreted  drugs 


Hemateporphyrin 


Unchanged  hemoglobin 

Pigments  in  food  (log- 
wood) matter,  bilbu- 
ries,  fuchsin. 

Hematin 

Methemoglobin 

Melanin 

Hydrochinol  and  catecho] 
Bile-pigments 


PATHOLOGICAL 
CONDITIONS. 


Nervous  conditions,  hy- 
druria,  diabetes  insipi- 
dus,  granular  kidney 

Acute  febrile  diseases 


Chyluria 

Purulent  diseases  of  the 
urinary  tract 

Santonin,    crysophanic 
acid 

or     hemo- 


globinuria 


Small  hemorrhages 
Methemoglobinuria 
Melanotic  sarcoma 

Carbolic  acid  poisoning 
Jaundice 


Cholera,  typhus ;  seen  es- 
pecially when  the  urine 
is  putrefying 


*This  dirty  green   or  blue 
organism. 


A  dark  blue  scum  on  sur- 
face, with  a  blue  de- 
posit, due  to  an  excess 
of  indigo-forming  sub- 
stances 

Substances  contained  in 
senna,  rhubarb,  and 
chelidonium  which  are 
introduced  into  the  sys- 
tem 

color  also   occurs  after  the   use   of   methylene   blue  in  the 


will  disappear  on  the  addition  of  acetic  acid.    Permanently  turbid 
urines  generally  arise  from  pathological  conditions. 


104  BLOOD    AND    URINE    CHEMISTRY 

Odor. — Normal  urine  has  a  faint  aromatic  odor.  On  standing 
a  long  time  all  urines  are  decomposed  (undergo  alkaline  fermenta- 
tion) and  have  a  very  unpleasant  ammoniacal  odor.  Certain  drugs 
(cubebs,  myrtol,  copaiba,  tolu,  saffron,  and  turpentine)  impart  a 
specific  odor  to  urine. 

Reaction. — The  urine  of  a  normal  individual  is  generally  acid  to 
litmus.  An  animal  diet  yields  an  acid  urine  while  a  vegetable  diet 
may  yield  a  neutral,  or  even  an  alkaline  urine.  The  composition  of 
the  food  taken  is  probably  the  most  important  factor  in  determin- 
ing the  reaction  of  the  urine.  The  reaction  also  varies  considerably 
according  to  the  time  of 'the  day  the  urine  is  passed.  For  instance, 
for  a  variable  length  of  time  after  a  meal  the  urine  may  be  neutral 
or  even  alkaline  to  litmus.  This  change  in  reaction  is  common  to 
perfectly  healthy  individuals.  Normal  urine  becomes  alkaline  on 
standing,  owing  to  the  conversion  of  urea  into  ammonium  carbonate 
by  bacteria. 

Specific  Gravity  and  Solids. — The  specific  gravity  of  normal 
urine  varies  ordinarily  between  1.015  and  1.025.  It  may,  however, 
be  as  low  as  1.003  or  as  high  as  0.040  without  necessarily  indicat- 
ing any  pathological  condition.  For  instance,  following  copious 
water  or  beer  drinking,  the  specific  gravity  may  become  as  low  as 
1.003  or  lower.  Whereas,  on  the  other  hand  in  cases  of  excessive 
perspiration  it  may  rise  as  high  as  1.040  or  even  higher. 

In  general  (normally  and  pathologically)  the  specific  gravity  is 
inversely  proportional  to  the  volume  excreted.  In  diabetes  mellitus, 
however,  we  may  observe  a  large  volume  and  a  high  specific  gravity 
owing  to  the  sugar  contained  in  the  urine. 

For  determining  the  specific  gravity  the  urinometer  commonly 
is  used  (Fig.  30).  This  is  sufficiently  accurate  for  clinical  pur- 
poses. The  urinometer  is  always  calibrated  for  use  at  a  certain 
temperature.  If  the  specific  gravity  is  taken  at  any  other  tempera- 
ture, correction  as  given  below  must  be  made.  In  making  this 
correction,  one  unit  of  the  last  order  is  added  for  every  three 
degrees  above  the  normal  temperature  and  substracted  for  every 
three  degrees  below  the  normal  temperature. 

Example. — The  urinometer  is  calibrated  for  15°  C. 

The  specific  gravity  of  the  urine  at  18°  C.  is  1022. 

The  true  specific  gravity  at  15°  C.  would  be  1.022  +  0.001  =  1.023. 


GENERAL   ANALYSIS 


105 


Solids. — The  amount  of  solids  in  1000  c.c.  may  roughly  be  cal- 
culated by  means  of  Long's  coefficient,  which  is  2.6.  This  is  ob- 
tained by  multiplying  the  last  two  figures  of  the  specific  gravity 
observed  at  25°  C.  by  2.6. 

Example.— The  twenty-four  hour  specimen  contains  1500  c.c. 

Specific  gravity  is  1016. 

(a)  16x2.6  =  41.6  grams  of  solid  matter  in  1000  c.c.  urine. 

(b)  41.6  x  1500  =  62.4  grams  of  solid  matter  in  1500  c.c.  urine. 

1000 
Toluene  is  very  satisfactory  for  preserving  urine.    This  is  simply 


Fig.  30. — Urinometer. 

poured  into  the  specimen  so  that  the  urine  is  overlaid*  with  the 
toluene. 

In  certain  pathological  conditions  it  is  desired  to  have  a  separate 
day  arid  night  urine.  The  urine  voided  between  8  A.  M.  and  8  P.  M. 
is  taken  as  the  day  sample,  and  that  voided  between  8  P.  M.  and 
8  A.  M.  is  taken  as  the  night  sample. 


106  BLOOD   AND   URINE    CHEMISTRY 

Glucose. 

Qualitative  Test  for  Glucose. — Place  about  5  c.c.  of  Benedict's 
qualitative  solution1  in  a  test  tube  and  add  8  to  10  drops  (not 
more)  of  the  urine  under  examination,  and  boil  the  mixture  vigor- 
ously for  a  minute  and  a  half.  It  is  allowed  to  cool  spontaneously. 
In  the  presence  of  dextrose,  the  entire  -body  of  the  solution  will 
be  filled  with  a  precipitate,  which  may  be  red,  yellow  or  green  in 
color,  depending  upon  the  amount  of  sugar  present.  (See  Plate 
IV  for  color  of  test  for  glucose.) 

If  the  amount  of  glucose  is  small  (under  0.3%)  the  precipitate 
forms  only  on  cooling.  If  the  urine  contains  no  sugar,  the  solution 
either  remains  perfectly  clear,  or  shows  a  faint  turbidity  that  is 
blue  in  color  and  consists  of  precipitated  urates,  and  should  cause 
no  confusion.  Even  very  small  quantities  of  dextrose  (0.1%)  yield 
precipitates  of  surprising  bulk  with  Benedict's  reagent. 

Benedict's  Quantitative  Estimation  of  Glucose.2 — The  titration 
method  of  Benedict  which  is  conceded  to  be  far  superior  to  the  older 
titration  methods  of  Fehling  and  Purdy,  is  the  method  which  is 
chosen.  This  method  gives  very  excellent  results  and  no  special  or 
expensive  apparatus  is  required.  It  is  superior  to  the  Lohnstein 
fermentation,  because  the  results  may  be  obtained  at  once  (about 
five  minutes).  It  is  also  superior  to  the  polariscope  method  in 
those  instances  when  levorotatory  substances  (as  /?-hydroxybutric 
acid)  are  present,  thus  necessitating  a  determination  both  before 
and  after  fermentation.  Place  the  urine  in  a  graduated  burette, 
pipette  25  c.c.  of  the  volumetric  solution3  into  a  Jena  flask  of  about 
150  c.c.  capacity,  and  add  5  to  10  grams  of  sodium  carbonate  and  a 
bit  of  powdered  pumice. 

Heat  the  mixture  to  boiling  on  a  piece  of  wire  gauze  with  an 
asbestos  mat  and  run  the  urine  in  rapidly  from  the  burette  until  a 
chalky  white  precipitate  begins  to  form.  (See  Fig.  31.)  Then  the 

'Benedict's  qualitative  solution  is  composed  of  17.3  grams  of  copper  sulphate,  173 
grams  of  sodium  citrate  and  100  grams  of  anhydrous  sodium  carbonate  (double  the 
weight  of  the  crystalline  salt  may  be  employed),  made  up  to  one  liter  with  distilled 
water.  In  the  preparation  of  the  solution,  the  copper  sulphate  should  be  dissolved  sep- 
arately in  about  100  to  150  c.c.  of  distilled  water  and  then  added  slowly  with  constant 
stirring  to  a  filtered  solution  (about  800  c.c.)  of  the  other  ingredients  and  finally  made 
up  to  one  liter.  This  solution  is  permanent. 

'Myers  and  Fine:     Essentials  of  Pathological  Chemistry,  1913. 

'Benedict's  volumetric  solution  also  keeps  permanently  and  is  composed  of  18:0  grams 
of  copper  sulphate,  100  grams  of  anhydrous  or  double  the  quantity  of  crystallized  sodium 
carbonate,  200  grams  of  sodium  or  potassium  citrate,  125  grams  of  potassium  sulpho- 
cyanate,  and  5  c.c.  of  a  5%  solution  of  potassium  ferrocyanide,  made  up  to  one  liter 
with  distilled  water.  In  preparation,  the  ingredients  are  dissolved  in  the  same  manner 
as  the  qualitative  reagent,  i.  e.,  the  copper  should  be  dissolved  separately. 


PJ,ATE  IV. — BENEDICTS'  TEST  FOR  SUGAR. 

1.  Green — Showing   only   a  Trace   of   Sugar. 

2.  Ked — Showing  a  Large  Amount  of  Sugar. 

3.  Yellow — Showing  a   Small  Amount   of   Sugar. 


GENERAL   ANALYSIS 


107 


Fig.  31  — Showing    Benedict's   method   for   the    quantitative   estimation    of   sugar. 


108  BLOOD   AND   URINE    CHEMISTRY 

urine  is  run  in  more  slowly  with  continuous  boiling,  until  the  last 
trace  of  blue  color  disappears,  indicating  the  end  point.  Chloror 
form,  if  present,  should  be  removed  by  boiling  as  it  interferes  with 
the  reaction.  Benedict  has  found  that  25  c.c.  of  the  above  copper 
solution  were  reduced  by  exactly  50  mgms.  of  glucose  or  52  mgms. 
of  levulose.  Myers  and  Fine  have  found  that  25  c.c.  of  the  above 
copper  solution  were  reduced  by  54  mgms.  of  galactose  or  67  mgms. 
of  lactose.  If  a  large  amount  of  glucose  is  present,  the  urine  should 
be  accurately  diluted  and  the  test  carried  out  in  the  same  way, 
the  final  results  being  multiplied  by  the  dilution. 

Example.- — The  twenty-four  hour  specimen  of  urine  contained 
2000  c.c. 

The  amount  of  urine  required  to  reduce  25  c.c.  of  Benedict's  volu- 
metric solution  (50  mgms.  glucose)  wyas  10  c.c.  Therefore  10  c.c. 
of  urine  contains  50  mgms.  of  glucose.  1  c.c.  contains  10  divided 
into  50  mgms.  or  5  mgms.  2000  c.c.  contains  10,000  mgms.  or  10 
grams  of  glucose. 

If  the  above  urine  were  diluted  one-half  before  examination,  the 
result  should  be  multiplied  by  2,  or  20  grams  of  glucose. 

Albumin. 

Normal  urine  contains  a  faint  trace  of  albumin  which  is  too 
slight  to  be  detected  by  any  ordinary  method. 

Nitric  Acid  Ring  Test  (Heller's  Test).— Place  1  c.c.  of  concen- 
trated nitric  acid  in  a  small  test  tube.  By  means  of  a  pipette  with 
a  rubber  bulb  on  one  end,  and  having  a  rugged  edge  on  the  other, 
allow  an  equal  amount  of  urine  to  run  gently  down  the  sides  of  the 
tube.  The  liquid  should  stratify,  and  if  albumin  is  present,  a  white 
ring  of  precipitated  albumin  should  appear  at  the  point  of  junc- 
ture. If  albumin  is  present  in  small  amounts,  the  white  ring  may 
not  appear  until  the  tube  has  been  allowed  to  stand  for  several 
minutes.  If  the  urine  is  concentrated  a  white  zone,  due  to  uric 
acid  or  urates,  may  form.  This  may  be  differentiated  from  the 
albumin  ring  by  diluting  the  concentrated  urine  with  three  or 
four  volumes  of  water.  The  experienced  worker  can  easily  differ- 
entiate between  the  uric  acid  ring  and  the  albumin  ring,  since  the 
uric  acid  ring  has  a  less  sharply-defined  upper  border,  is  generally 
broader  than  the  albumin  ring,  and  is  often  situated  above  the 


GENERAL    ANALYSIS 


109 


point  of  contact.  Various  colored  zones  due  to  bile  pigments,  etc., 
may  also  appear,  but  this  should  not  confuse  the  worker.  After  the 
administration  of  certain  drugs,  a  white  precipitate  of  resin  acids 
may  form  at  the  point  of  contact  and  may  cause  the  observer  to 
draw  wrong  conclusions.  This  ring  (if  composed  of  resin  acids) 
will  dissolve  in  alcohol,  whereas  the  albumin  ring  will  not. 
.  Robert's  Test  for  Albumin. — Into  a  small  test  tube  introduce 
1  c.c.  of  Robert's  reagent.3  By  means  of  a  pipette  with  a  rubber 
bulb  on  one  end,  having  a  rugged  edge  on  the  other,  allow  an  equal 
amount  of  urine  to  run  gently  down  the  sides  of  the  tube.  The 


Fig.   32. — Graduated   cc 


liquids  should  stratify,  and  if  albumin  is  present  a  white  zone  of 
precipitated  albumin  should  appear  at  the  point  of  juncture.  This 
test  is  slightly  more  sensitive  than  Heller's  test  and  colored  rings 
do  not  appear,  but  if  uric  acid  or  urates  are  present,  a  white  zone 
may  also  appear  and  can  be  differentiated  from  albumin  by  dilu- 
tion as  in  Heller's  test. 

Quantitative  Estimation  of  Protein  (Purdy).— Into  a  15  c.c. 
graduated  conical  centrifuge  tube  (Fig.  32)  place  10  c.c.  of  clear 
urine,  3  c.c.  of  10%  potassium  ferrocyanide,  and  2  c.c.  of  50% 
acetic  acid.  Shake  the  tube  and  set  aside  for  10  minutes  to  allow 
for  the  precipitation  of  the  albumin,  centrifuge  the  tube  for  exact- 


3Robert's    reagent    is    prepared    by    mixing    fh 
and  one  part  of  concentrated  nitric  acid. 


parts    of    saturated    magnesium    sulphate 


110 


BLOOD    AND   URINE    CHEMISTRY 


ly  three  minutes,  at  1500  revolutions  per  minute,  in  an  instrument 
with  a  radius,  including  the  tubes,  of  just  6%  inches.  Then  take 
the  tube  out  of  the  centrifuge  and  the  grams  of  protein  per  liter 
are  read  off  from  the  following  table  (see  Table  X) .  If  the  amount 
of  protein  is  very  large,  the  urine  should  be  accurately  diluted. 

Example. — Precipitate  in  centrifuge  tube  is  1.25  which  is  equal 
to  2.6  grams  of  protein  per  1000  c.c.  24  hour  specimen  contains 
1500  c.c.  Multiply  2.6  by  1.5,  equals  3.9  grams  of  protein  in  1500 
c.c. 

TABLE  X 


VOLUME  OF 

DRY  WEIGHT 

VOLUME  OF 

DRY  WEIGHT 

PRECIPITATE  IX 

OF  PROTEIN 

PRECIPITATE  IN 

OF  PROTEIN 

GRADUATED  TUBE 

TO  LITER 

GRADUATED  TUBE 

TO  LITER 

0.25 

0.5 

2.75 

5.7 

0.5 

1.0 

3.0 

6.3 

0.75 

l.G 

3.25 

6.8 

1.0 

2.1 

3.50 

7.3 

1.25 

2.6 

3.75 

7.8 

1.5 

3.1 

4.0 

8.3 

1.75 

3.C 

4.25 

8.9 

2.0 

4.2 

4.50 

9.4 

2.25 

4.7 

4.75 

9.9 

2.5 

5.2 

5.0 

10.4 

Acetone. 

To  10  c.c.  of  urine  in  a  test  tube  add  about  one  gram  of  am- 
monium sulphate,  2  to  3  drops  of  a  freshly  prepared  5%  solu- 
tion of  sodium  nitroprusside,  and  2  c.c.  of  concentrated  ammonium 
hydroxide  which  may  be  stratified  or  poured  on  the  mixture.  The 
presence  of  acetone  is  indicated  by  the  slow  development  of  a 
permanganate  color.  (See  Plate  III  for  acetone  color.)  The  deli- 
cacy of  this  reaction  is  1  to  20,000.  Pathologically,  the  elimination 
of  acetone  (acetonuria)  is  said  to  accompany  the  following: 

1.  Diabetes  mellitus. 

2.  Scarlet  fever. 

3.  Typhoid  fever. 

4.  Pneumonia. 

5.  Nephritis. 

6.  Phosphorous  poisoning. 

7.  Fasting. 


GENERAL   ANALYSIS  111 

8.  Grave  anemias. 

9.  Deranged  digestive  function. 
It  also  frequently  accompanies : 

1.  Autointoxication. 

2.  Chloroform  anesthesia. 

3.  Ether  anesthesia. 

It  is  believed  that  the  output  of  acetone  arises  principally  from 
the  breaking  down  of  fatty  tissues  or  fatty  food  within  the  organ- 
ism. The  acetone  elimination  has  been  shown  to  increase  when 
the  patient  is  fed  an  abundance  of  fat-containing  food  as  well  as 
during  fasting.  In  fasting,  the  decomposition  of  fat  is  increased 
due  to  the  lack  of  carbohydrate  material  and  acidosis  develops.  The 
same  is  true  with  a  carbohydrate-free  diet. 

Diacetic  Acid. 

Diacetic  acid  generally  is  excreted  under  the  same  pathological 
conditions  as  in  acetonuria,  diabetes,  fevers,  etc. 

Gerhardt's  Test. — To  about  5  c.c.  of  urine  in  a  test  tube  add 
ferric  chloride  solution,  drop  by  drop,  until  no  more  precipitate 
forms.  If  diacetic  acid  is  present,  a  violet-red  or  Bordeaux-red  is 
produced.  A  variety  of  drugs  or  their  derivatives  will  give  a  posi- 
tive reaction  when  present  in  the  urine  so  that  a  positive  result  in- 
dicates the  possible  presence  of  diacetic  acid.  If  confusion  due  to 
drugs  is  suspected,  boil  the  red  solution  for  2  to  3  minutes.  If  the 
color  is  due  to  diacetic  acid,  it  should  disappear  during  boiling 
and  not  reappear  on  cooling.  (See  Plate  III  for  diacetic  acid 
color.) 

Acetone  Bodies  in  Urine 

Van  Slyke  and  Fitz4  have  introduced  a  very  good  method 
for  the  determination  of  the  so-called  acetone  bodies  in  urine ; 
namely  beta-hydroxybutyric  acid,  acetoacetic  acid  and  acetone. 
(See  page  77  for  similar  determinations  on  blood.)  The* methods 
are  based  on  a  combination  of  Shaffer's  oxidation  of  beta- 
hydroxybutyric  acid  to  acetone  and  Deniges'  precipitation  of  ace- 
tone as  a  basic  mercuric  sulphate  compound.  Oxidation  and  pre- 
cipitation are  carried  out  simultaneously  in  the  same  solution  so 


4Van    Slyke   and    Fitz:     Jour.    Biol.    Chem.,    1917, 


1.12  BLOOD   AND    URINE    CHEMISTRY 

that  the  technic  is  simplified  to  boiling  the  mixture  for  an  hour 
and  a  half  under  a  reflux  condenser,  and  weighing  the  precipitate 
which  forms.  The  acetone  and  acetoacetic  acid  may  be  de- 
termined either  with  beta-oxybutyric  acid  or  separately.  Neither 
the  size  of  the  sample  nor  mode  of  procedure  have  required  varia- 
tion for  different  urines;  the  same  process  may  be  used  for  the 
smallest  significant  amounts  of  acetone  bodies  and  likewise  for 
the  largest  that  are  encountered.  The  precipitate  is  crystalline 
and  beautifully  adapted  to  quick  drying  and  accurate  weighing ; 
but  when  facilities  for  weighing  are  absent  the  precipitate  can 
be  redissolved  in  dilute  hydrochloric  acid  and  the  mercury  ti- 
trated with  potassium  iodide  by  the  method  of  Personne  (18631). 
Preservatives  other  than  toluene  or  copper  sulphate  should  not 
be  used. 

Solutions  Required. — 20  per  cent  copper  sulphate. — 200 
gm.  of  CuS045H20  dissolved  in  water  and  made  up  to 
one  liter. 

10  per  cent  mercuric  sulphate. — 73  gm.  of  pure  red  mer- 
curic oxide  dissolved  in  1  liter  of  H2S04  of  4  n  concen- 
tration. 

50  volume  per  cent  sulphuric  acid. — 500  c.c.  sulphuric 
acid  of  1.835  specific  gravity,  diluted  to  1  liter  of  water. 
Concentration  of  H2S04  must  be  readjusted  if  necessary 
to  make  it  17:0  n  by  titration. 

10  per  cent  calcium  hydroxide  suspension. — Mix  100  gm. 
of  Merck's  fine  light  "reagent"  Ca(OH)2  with  1  liter 
of  water. 

5  per  cent  potassium  dichromate. — 50  gm.   of  K,Cr207 
dissolved  in  water  and  made  up  to  1  liter. 
Combined  reagents  for  total   acetone   body   determina- 
tion.—One  liter  of  the  above  50  per  cent  sulphuric  acid, 
3.5  liters  of  the  mercuric  sulphate,  10  liters  of  water. 
Removal  of  the  Glucose  and  Other  Interfering  Factors. — Place 
25  c.c.  urine  in  a  250  c.c.  measuring  flask.     Add  100  c.c.  water, 
50  c.c.  copper  sulphate  solution,  and  mix.     Then  add  50  c.c.  of 
10  per  cent  calcium  hydroxide,  shake  and  test  with  litmus.     If 
not  alkaline,  add  more  calcium  hydroxide.     Dilute  to  the  mark 
and  let  stand  at  least  one-half  hour  for  glucose  to  precipitate. 


GENERAL   ANALYSIS  113 

Filter  through  a  dry  folded  filter.  This  will  remove  up  to  8  per 
cent  of  glucose.  Urine  containing  more  than  this  amount  should 
be  diluted  to  bring  the  glucose  down  to  below  8  per  cent.  The 
copper  treatment  can  be  depended  upon  to  remove  all  inter- 
fering factors  other  than  glucose  and  should  never  be  omitted 
even  though  glucose  'is  absent.  Test  the  nitrate  for  glucose  re- 
moval by  boiling  when  cuprous  oxide  will  be  thrown  down  if  all 
the  glucose  has  not  been  removed.  A  slight  precipitation  of 
white  calcium  salts  always  forms,  but  does  not  interfere  with  the 
detection  of  the  yellow  cuprous  oxide. 

Simultaneous  Determination  of  Total  Acetone  Bodies  (Acetone, 
Acetoacetic  Acid,  and  Hydroxybutyric  Acid)  in  One  Opera- 
tion.— Place  in  a  500  c.c.  Erlenmeyer  flask  25  c.c.  of  urine  filtrate. 
Add  100  c.c.  of  water,  10  c.c.  of  50  per  cent  sulphuric  acid,  and 
35  c.c.  of  the  10  per  cent  mercuric  sulphate.  Or  in  place  of 
adding  the  water  and  reagents  separately,  add  145  c.c.  of  the 
''combined  reagents."  Connect  the  flask  with  a  reflux  condenser 
having  a  straight  condensing  tube  of  8  or  10  mm.  diameter  and 
heat  to  boiling.  After  boiling  has  begun,  add  5  c.c.  of  the  5  per 
cent  dichromate  through  the  condenser  tube.  Continue  boiling 
gently  one  and  one-half  hours.  The  yellow  precipitate  which 
forms  consists  of  the  mercury  sulphate-chromate  compound  of 
the  preformed  acetone,  and  of  the  acetone  which  has  been  formed 
by  decomposition  of  acetoacetic  acid  and  by  oxidation  of  the 
hydroxybutyric  acid.  It  is  collected  in  a  Gooch  or  "medium 
density"  alundum  crucible,  washed  with  200  c.c.  of  cold  water, 
and  dried  for  an  hour  at  110  degrees.  The  crucible  is  allowed 
to  cool  in  room  air  (a  dessicator  is  unnecessary  and  undesirable) 
and  weighed.  Several  precipitates  may  be  collected,  one  above 
the  other,  without  cleaning  the  crucible.  As  an  alternative  to 
weighing,  the  precipitate  may  be  dissolved  and  titrated,  as  de- 
scribed below. 

Acetone  and  Acetoacetic  Acid. — The  acetone  plus  the  aceto- 
acetic acid,  which  completely  decomposes  into  acetone  and  C02 
on  heating,  is  determined  without  the  hydroxybutyric  acid  ex- 
actly as  the  total  acetone  bodies,  except  that  (1)  110  dichromate 
is  added  to  oxidize  the  hydroxybutyric  acid  and  (2)  the  boil- 
ing must  continue  for  not  less  than  30  or  more  than  45  minutes. 


114  BLOOD   AND   URINE    CHEMISTRY 

Boiling  for  more  than  45  minutes  splits  off  a  little  acetone  from 
hydroxybutyric  acid  even  in  the  absence  of  chromic  acid. 

Beta-Hydroxybutyric  Acid. — The  hydroxybutyric  acid  alone  is 
determined  exactly  as  total  acetone  bodies,  except  that  the  pre- 
formed acetone  and  that  from  the  acetoacetic  acid  are  first  boiled 
off.  To  do  this  the  25  c.c.  of  urine  filtrate  plus  100  c.c.  of  water 
are  treated  with  2  c.c.  of  the  50  per  cent  sulphuric  acid  and  boiled 
in  the  open  flask  for  10  minutes.  The  volume  of  solution  left 
in  the  flask  is  measured  in  a  cylinder.  The  solution  is  returned 
to  the  flask,  and  the  cylinder  washed  with  enough  water  to 
replace  that  boiled  off  and  restore  the  volume  of  the  solution  to 
127  c.c.  Then  8  c.c.  of  the  50  per  cent  sulphuric  acid  and  35  c.c. 
of  mercuric  sulphate  is  added.  The  flask  is  connected  under  the 
condenser  and  the  determination  is  continued  as  described  for 
total  acetone  bodies. 

Blank  Determination  of  Precipitate  from  Substances  in  Urine 
Other  than  the  Acetone  Bodies. — The  25  c.c.  aliquot  of  urine  fil- 
trate is  treated  with  sulphuric  acid  and  water  and  boiled  10  min- 
utes to  drive  off  acetone.  The  residue  is  made  up  to  175  c.c.  with 
the  same  amounts  of  sulphuric  acid  used  in  the  above  determina- 
tion, but  without  chromate,  and  is  boiled  under  the  reflux  for 
45  minutes.  Longer  boiling  splits  off  some  acetone  from  beta- 
hydroxybutyric  acid,  and  must  therefore  be  avoided.  The  weight 
of  precipitate  obtained  may  be  subtracted  from  that  obtained  in 
the  above  determination. 

The  blank  is  so  small  that  in  our  experience  it  is  relatively  sig- 
nificant only  when  compared  with  the  small  amounts  of  acetone 
bodies  found  in  normal  or  nearly  normal  urines.  In  routine 
analyses  of  diacetic  urines  we  do  not  determine  it. 

Test  of  Reagents. — When  the  complete  total  acetone  bodies  de- 
termination, including  the  preliminary  copper  sulphate  treat- 
ment, is  performed  on  a  sample  of  distilled  water  instead  of 
urine  no  precipitate  whatever  should  be  obtained.  This  test  must 
not  be  omitted. 

Titration  of  the  Precipitate. — Instead  of  weighing  the  precipi- 
tate, one  may  wash  the  contents  of  the  Gooch,  including  the  as- 
bestos, into  a  small  beaker  with  as  little  water  as  possible,  and 
add  15  c.c.  of  1  n  IIC1.  The  mixture  is  then  heated,  and  the 


GENERAL   ANALYSIS  115 

precipitate  quickly  dissolves.  In  case  an  alundum  crucible  is 
used,  it  is  set  into  a  beaker  of  acid  until  the  precipitate  dissolves, 
and  then  washed  with  suction,  the  washings  being  added  to  the 
beaker.  In  place  of  using  either  a  Gooch  or  alundum  crucible 
one  may,  when  titration  is  employed,  wash  the  precipitate  with- 
out suction  on  a  small  quantitative  filter  paper,  which  is  trans- 
ferred with  precipitate  to  the  beaker  and  broken  up  with  a  rod 
in  15  c.c.  of  1  n  HC1. 

In  order  to  obtain  a  good  end-point  in  the  subsequent  titra- 
tion, it  is  necessary  to  reduce  the  acidity  of  the  solution.  For 
this  purpose  we  have  found  addition  of  excess  sodium  acetate  the 
most  satisfactory  means.  Six  to  7  c.c.  of  3  m.  acetate  are  added 
to  the  cooled  solution  of  redissolved  precipitate.  Then  the  0.2 
m.  KI  is  run  in  rapidly  from  a  burette  with  constant  stirring.  If 
more  than  a  small  amount  of  mercury  is  present,  a  red  precipi- 
tate of  HgI2  at  once  forms,  and  redissolves  as  soon  as  2  or  3  c.c. 
of  KI  in  excess  of  the  amount  required  to  form  the  soluble 
K2HgI4  have  been  added.  .If  only  a  few  mgm.  of  mercury 
are  present,  the  excess  of  KI  may  be  added  before  the  HgI2  has 
had  time  to  precipitate,  so  that  the  titrated  solution  remains  clear. 
In  this  case  not  less  than  5  c.c.  of  the  0.2  m.  KI  are  added,  as  it 
has  been  found  that  the  final  titration  is  not  satisfactory  if  less 
is  present.  The  excess  of  KI  is  titrated  back  by  adding  0.05  m. 
HgCl2  from  another  burette  until  a  permanent  red  precipitate 
forms.  Since  the  reaction  utilized  is  HgCl2  +  4  KI  =  K2HgI4  + 
2KC1,  1  cc.  of  0.05  m.  HgCl2  is  equivalent  in  the  titration  to  1  c.c. 
of  the  0.2  m.  KI. 

In  preparing  the  two  standard  solutions  the  0.05  m.  HgCl2  is 
standardized  by  the  sulphide  method,  and  the  iodide  is  standard- 
ized by  titration  against  it.  A  slight  error  appears  to  be  intro- 
duced if  the  iodide  solution  is  gravimetrically  standardized  and 
used  for  checking  the  mercury  solution,  instead  of  vice  versa. 

In  standardizing  the  mercuric  chloride  we  have  found  *the  fol- 
lowing procedure  convenient:  25  c.c.  of  0.05  m.  HgCl2  are  meas- 
ured with  a  calibrated  pipette,  diluted  to  about  100  c.c.,  and 
H2S  is  run  in  until  the  black  precipitate  flocculates  and  leaves  a 
clear  solution.  The  HgS,  collected  in  a  Gooch  crucible  and  dried 
at  110  degrees,  should  weigh  0.2908  gm.  if  the  solution  is/ ac- 
curate. 


BLOOD    AND    UHINK    CHEMISTRY 


Both  by  gravimetric  analyses  of  the  basic  mercuric  sulphate- 
acetone  precipitate  and  by  titration,  we  find  the  mercury  content 
of  the  precipitate  to  average  76.9  per  cent.  On  this  basis  each 
c.c.  of  0.2  m.  KI  solution,  being  equivalent  to  10.0  mg.  of  Hg,  is 

10.0 
equivalent  to       ",    =  13.0  mg.  of  the  mercury  acetone  precipitate. 

Titration  is  not  quite  so  accurate  as  weighing,  but,  except  when 
the  amounts  determined  are  very  small,  the  titration  is  satisfac- 
tory. 

Factors    for    Calculating    Results. — 1    mg.    of    beta- 
hydroxybutyric  acid  yields  8.45  mg.  of  precipitate. 
1  mg.  of  acetone  yields  20.0  mg.  of  precipitate. 
1  c.c.  of  0.2  in.  KI  solution  is  equivalent  to  13  mg.  of 
precipitate  in  titration  of  the  latter. 

SPECIAL  FACTORS  FOR  CALCULATION  OF  RESULTS  WHEN  25  c.c.  OF  URINE  FIL- 
TRATE EQUIVALENT  TO  2.5  c.c.  OF  URINE  ARE  USED  FOR  THE  DETERMINATION 


ACETONE     LfODIi;S     CALCULATED     AS     GM. 
ACETONE   PER   LITER    OF    URINE,   INDI- 
CATED  BY 

1    gni.    of 
precipitate 

1  c.c.  of  0.2  M.  KI 
solution 

Total  acetone  bodies  
Beta-hydroxybutyric  acid 

24.8 
26.4 
20.0 

0.322 
0.344 
0.260 

Acetone  plus  acetoacetic  acid  

The  "total  acetone  bodies"  factor  is  calculated  on  the  as- 
sumption that  the  molecular  proportion  of  them  in  the  form  of 
beta-liydroxybutyric  acid  is  75  per  cent  of  the  total,  which  pro- 
portion is  usually  approximated  in  acetonuria.  Because  hy- 
droxybutyric  acid  yields  only  0.75  molecule  of  acetone,  the  fac- 
tors are  strictly  accurate  only  when  this  proportion  is  present, 
but  the  error  introduced  by  the  use  of  the  approximate  factors 
is  for  ordinary  purposes  not  serious.  The  actual  errors  in  per- 
centages of  the  amounts  determined  are  as  follows:  molecular 
proportion  of  acetone  bodies  as  beta-acid  50,  error  -  6.5  per  cent ; 
beta-acid  0.60,  error  -  3.8  per  cent;  beta-acid  0.80,  error  1.3  per 
cent. 

In  order  to  calculate  the  acetone  bodies  as  beta-hydroxybutyric 


GENERAL   ANALYSIS  117 

acid  rather  than  acetone,  use.  the  above  factors  multiplied  by  the 

beta-acid      104        .,  r-nr, 

ratio  of  the  molecular  weights —  — =-^r  =  1.79«.    In  order 

acetone          58 

to  calculate  the  acetone  bodies  in  terms  of  molecular  concentra- 
tion, divide  the  factors  in  the  table  by  58.  To  calculate  c.c.  of 
0.1  m.  acetone  bodies  per  liter  of  urine,  use  the  above  factors 

multiplied  by  ^ —  =  172.4. 

Jo 

Indican. 

Normally,  5  to  20  milligrams  of  indican  are  eliminated  in  24 
hours.  This  amount  is  greatly  increased  in  conditions  of  excessive 
intestinal  putrefaction.  Of  the  putrefaction  products,  the  indole, 
skatole,  phenol  and  paracresol  appear  in  part  in  the  urine  as 
ethereal  sulphuric  acids,  whereas  the  oxyacids  pass  unchanged  into 
the  urine.  The  potassium  indoxyl  sulphate  content  in  the  urine 
is  a  rough  indicator  of  the  extent  of  the  putrefaction  within  the  in- 
testine. The  portion  of  the  indole  which  is  excreted  in  the  urine 
is  subjected  to  a  series  of  changes  within  the  organism  and  is 
eliminated  as  indican. 

Obermayer's  Test. — Shake  about  10  c.c.  of  faintly  acid  urine  with 
about  0.1  gram  of  basic  lead  acetate,  and  filter.  To  the  clear  filtrate 
in  a  test  tube  add  an  equal  volume  of  Obermayer's  reagent,4  and 
about  3  c.c.  to  5  c.c.  of  chloroform.  Place  the  thumb  over  the 
mouth  of  the  tube  and  shake  vigorously.  On  standing  a  few 
minutes  the  chloroform  will  settle  and  it  will  assume  a  blue  color, 
if  indican  is  present.  (See  Plate  III  for  color  of  indican  test.) 
The  intensity  of  the  color  will  vary  with  the  amount  of  indigo 
blue  which  has  been  brought  into  solution  by  the  chloroform.  Nor- 
mally, the  chloroform  should  assume  only  a  faint  blue  color.  In 
other  words,  normal  urine  contains  a  trace  of  indican.  Qualita- 
tively, the  depth  of  blue  color  may  be  taken  as  indicating  the  de- 
gree of  indicanuria,  i.  e.,  a  defep  blue  indicates  a  large  amount  of 
indican  present. 

Phosphates. 

The  total  output  of  phosphoric  acid  is  extremely  variable,  but  the 
average  excretion  as  P205  in  24  hours  is  about  2.5  grams. 


4Obermayer's  reagent  is  prepared  by  dissolving  about  3  grams  of   ferric  chloride  in   one 
liter   of   concentrated   hydrochloric   acid. 


118  BLOOD   AND    URINE    CHEMISTRY 

Pathological  conditions  in  which  the  excretion  of  phosphates  is 
increased : 

1.  Diffuse  periostitis. 

2.  Osteomalacia. 

3.  Rickets. 

4.  Copious  water  drinking. 

Some  investigators  claim  that  the  excretion  of  phosphates  is  also 
increased  in  the  following: 

1.  Early  stages  of  pulmonary  tuberculosis. 

2.  Diseases  which  are  accompanied  by  an  extensive  decomposi- 
tion of  nervous  tissue. 

3.  Acute  yellow  atrophy  of  the  liver. 

4.  After  sleep  induced  by  potassium  bromide  or  chloral  hydrate. 
Pathological  conditions  in  which  the  excretion  of  phosphates  is 

decreased : 

1.  Acute  infectious  diseases. 

2.  Pregnancy  (in  the  period  during  which  the  fetal  bones  are 
forming) . 

3.  Diseases  of  the  kidney  (due  to  nonelimination). 

Test  for  Phosphates. — Place  50  c.c.  of  urine  in  a  beaker  or  Er- 
lenmeyer  flask,  add  5  c.c.  of  accessory  solution,5  and  heat  to  the 
boiling  point.  A  standard  solution  of  uranium  nitrate6  is  then  run 
from  a  burette  into  the  hot  solution  (drop  by  drop)  until  the  pre- 
cipitate ceases  to  form.  A  drop  of  the  mixture  brought  into  con- 
tact with  a  drop  of  10%  solution  of  potassium  ferrocyanide  on  a 
porcelain  tablet  (Fig.  33)  should  produce  a  brownish-red  color. 
If  this  color  does  not  appear,  more  standard  uranium  nitrate  solu- 
tion should  be  added,  i.e.,  until  the  brownish-red  color  appears. 
The  reading  on  the  burette  is  taken  and  is  calculated  as  follows: 

Multiply  the  reading  on  the  burette  by  0.005  to  obtain  the  grams 
of  P205  in  50  c.c.  of  urine. 

Example. — 24  hour  specimen  contains  1500  c.c.  urine. 

BFor  the  preparation  of  the  accessory  solution,  dissolve  100  gms.  of  sodium  acetate  in 
about  800  c.c.  distilled  water,  then  add  100  c.c.  30%  acetic  acid  to  the  solution  and  make 
up  to  one  liter  with  distilled  water. 

•For  the  preparation  of  uranium  nitrate,  dissolve  44.8  grams  of  uranium  nitrate  in 
about  900  c.c.  of  distilled  water.  Titrate  this  solution  with  a  standard  phosphate  solu- 
tion containing  0.005  gram  of  P2OS  per  cubic  centimeter.  This  standard  phosphate  is 
prepared  by  dissolving  14.721  grams  of  pure  air-dry  sodium  ammonium  phosphate 
(NaNH4HPO4+4  H2O)  in  distilled  water  and  making  up  to  one  liter.  The  amount  of 
water  to  be  added  to  the  uranium  nitrate  solution  so  that  1  c.c.  will  be  equivalent  to 
O.OOS  gram  of  PzOs  can  be  calculated. 


GENERAL   ANALYSIS 


119 


Reading  on  burette  is  10.2. 

10.2  x  0.005  =  0.051  gram  of  P205  in  50  c.c.  urine. 

0.051  x  30  =  1.53  grams  of  P2O5  in  1500  c.c.  urine. 


Fig.  33. — Porcelain  tablet  for  the  determination  of  phosphates. 

Sulphates 

Sulphur  is  present  in  the  urine  in  three  forms, — (a)  preformed 
or  neutral  sulphates,  (b)  ethereal  or  conjugated  sulphates,  sul- 
phuric acid  in  combination  with  aromatic  compounds,  and  (c) 
neutral,  unoxidized,  or  organic  sulphur. 

The  total  sulphate  excretion  (ethereal  and  inorganic  sulphates) 
by  a  normal  adult  on  a  mixed  diet  varies  from  1.5  grams  to  3.0 
grams  of  S03  with  an  average  of  about  2.0  grams.  This  excre- 
tion varies  widely  with  the  protein  content  of  the  diet. 

The  excretion  of  sulphates  is  increased  in  all  conditions  as- 
sociated with  increased  decomposition  of  body  protein  as  in  acute 
fevers  and  decreased  whenever  there  is  a  decrease  in  metabolic 
activity.  The  increase  is  especially  marked  in  acute  inflamma- 
tory disease  of  the  brain  and  cord,  pneumonia,  acute  myelitis, 
and  in  acute  articular  rheumatism.  It  is  increased  after  proto- 
plasmic poisons.  It  is  decreased  during  convalescence  from  an 
acute  fever  and  in  practically  all  chronic  diseases. 

Total  Sulphates. — Folin's  Method. — Place  25  c.c.  of  urine  in 
a  250  c.c.  Erlenmeyer  flask  and  add  20  c.c.  of  dilute  hydro- 


120  BLOOD    AND    URINK    CHEMISTRY 

chloric  acid  (one  volume  of  concentrated  hydrochloric  acid  to 
four  volumes  of  water).7 

Gently  boil  the  mixture  for  20  to  30  minutes.  The  mouth  of 
the  flask  should  be  covered  with  a  small  watchglass  during  the 
boiling  so  as  to  prevent  the  loss  of  material.  Cool  the  flask  for 
2  to  3  minutes  in  cold  running  water,  and  dilute  the  contents  with 
cold  water  to  about  150  c.c.  Add  10  c.c.  of  a  5  per  cent  solution 
of  barium  chloride  slowly,  drop  by  drop,  to  the  cold  solution. 
It  should  take  from  2  to  3  minutes  to  add  the  barium  chloride. 
The  contents  of  the  flask  should  not  be  stirred  or  shaken  during 
the  addition  of  the  barium  chloride.  Allow  the  mixture  to  stand 
at  least  one  hour,  then  filter  through  a  weighed  Gooch  crucible  or 
an  ash-free  filter  (preferably  a  Gooch  filter).  Wash  the  precipi- 
tate of  barium  sulphate  with  about  250  c.c.  of  cold  water,  dry  it 
in  an  air-bath  or  over  a  very  low  flame,  then  ignite.8 

Cool  and  weigh. 

Subtract  the  weight  of  the  Gooch  crucible  from  the  weight  of 
the  crucible  and  the  barium  sulphate  precipitate  to  obtain  the 
weight  of  the  precipitate.  The  weight  thus  obtained  multiplied 
by  0.3429  will  give  the  amount  of  S03  in  the  urine  used  in  the  de- 
termination. 

Example. — Suppose  the  24-hour  specimen  of  urine  contains  1500 
c.c.  and  the  weight  of  the  Gooch  crucible  and  the  barium  sulphate 
precipitate  is  5.15  gms..  and  the  weight  of  the  Gooch  crucible 
is  5.0  gms.  The  result  is  obtained  in  the  following  way: 

Subtract  5.0  from  5.15,  equals  0.15,  0.3429  times  0.15  equals 
0.051435  gm.  in  25  c.c.  of  urine.  Multiply  by  4,  equals  0.205740 
gm.  in  100  c.c.  Multiply  by  15  equals  3.0861  gms.  in  the  24-hour 
specimen. 

Inorganic  Sulphates. — Folin's  Method. — Place  25  c.c.  of  urine 
and  100  c.c.  of  water  in  an  Erlenmeyer  flask  of  250  c.c.  capacity 
and  acidify  the  diluted  urine  with  10  c.c.  of  diluted  hydrochloric 
acid  (one  volume  of  concentrated  hydrochloric  acid  to  four  vol- 
umes of  water).  If  the  urine  is  dilute,  50  c.c.  may  be  used  and 
50  c.c.  of  water  instead  of  100  c.c.  Add  10  c.c.  of  a  5  per  cent 


7If  it  is  desired  50  c.c.  of  urine  and  4  c.c.  of  concentrated  hydrochloric  acid  may  be 
used  instead. 

"Care  should  be  taken  in  the  ignition  of  precipitates  in  Gooch  crucibles.  In  case  a 
porcelain  Gooch  crucible  is  used,  it  should  be  placed  upon  the  lid  of  an  ordinary  platinum 
disli  during  ignition.  Ignition  will  be  complete  in  about  ten  minutes  if  no  organic  mat- 
ter is  present.  fc 


GENERAL    ANALYSIS  121 

solution  of  barium  chloride  slowly  drop  by  drop,  to  the  cold 
solution.  It  should  take  from  2  to  3  minutes  to  add  the  barium 
chloride.  The  contents  of  the  flask  should  not  be  stirred  or 
shaken  during  the  addition  of  the  barium  chloride.  Allow  the 
mixture  to  stand  at  least  one  hour,  then  shake  up  the  solution 
well  and  filter  it  through  a  weighed  Gooch  crucible  or  an  ash- 
free  filter  (preferably  a  Gooch  filter).  Wash  the  precipitate  of 
barium  sulphate  with  about  250  c.c.  of  cold  water,  dry  it  in  an 
air-bath  or  over  a  very  low  flame,  then  ignite.9 

Cool  and  weigh. 

Subtract  the  weight  of  the  Gooch  crucible  from  the  weight  of 
the  crucible  and  the  barium  sulphate  precipitate  to  obtain  the 
weight  of  the  precipitate.  The  weight  thus  obtained  multiplied 
by  0.3429  will  give  the  amount  of  inorganic  sulphates  expressed 
as  SG:J  in  the  urine  used  in  the  determination.  (See  example 
above.) 

Ethereal  Sulphates. — Folin's  Method.— Place  125  c.c.  of  urine 
in  an  Erlenmeyer  flask  of  about  500  c.c.  capacity  and  dilute  it 
with  75  c.c.  of  water.  Acidify  the  contents  of  the  flask  with  30  c.c. 
of  dilute  hydrochloric  acid  (one  volume  of  concentrated  hydro- 
chloric acid  to  four  volumes  of  water).  To  this  cold  solution 
add  20  c.c.  of  a  5  per  cent  solution  of  barium  chloride  drop  by 
drop.  It  should  take  from  2  to  3  minutes  to  add  the  barium 
chloride.  The  contents  of  the  flask  should  not  be  stirred  or  shaken 
during  the  addition  of  the  barium  chloride.  Allow  the  mixture 
to  stand  for  about  a  half  hour,  and  filter  it  through  a  dry  filter 
paper.  Collect  125  c.c.  of  the  filtrate  and  boil  it  gently  for  at 
least  a  half  hour.  •  The  mouth  of  the  flask  should  be  covered  with 
a  small  watchglass  during  the  boiling  so  as  to  prevent  the  loss 
of  material.  Cool  the  solution  in  cold  running  water  for  from 
2  to  3  minutes,  filter  off  the  precipitate  of  barium  ( sulphate 
through  a  weighed  Gooch  crucible  or  ash-free  filter  (preferably 
a  Gooch  crucible).  Wash  the  precipitate  of  barium  sulphate  with 
about  250  c.c.  of  water,  dry  in  an  air-bath  or  over  a  very  low 
flame,  then  ignite.10 

Cool  and  weigh. 

In  calculation  the  weight  of  the  barium  sulphate  precipitate 


"See   Footnote  No.  8,  p.    120. 
10See  Footnote  No.  8,  p.  120. 


122  BLOOD   AND   URINE    CHEMISTRY 

should  be  multiplied  by  2  since  only  one-half  (125  c.c.)  of  the 
total  volume  (250  c.c.)  of  fluid  was  precipitated  by  the  barium 
chloride.  Subtract  the  weight  of  the  Gooch  crucible  from  the 
weight  of  the  crucible  and  the  precipitate  to  obtain  the  weight 
of  the  precipitate.  This  weight  should  be  multiplied  by  2  (see 
statement  above).  The  result  thus  obtained  multiplied  by 
0.3429  will  give  the  amount  of  ethereal  sulphates  expressed  as 
S03  in  the  urine  used  in  the  determination.  (See  example  above.) 

Total  Sulphur. — Benedict's  Method. — Place  10  c.c.  of  urine  in 
a  small  evaporating  dish  and  add  5  c.c.  of  Benedict's  sulphur 
reagent.11 

The  contents  of  the  dish  are  evaporated  over  a  free  flame  which 
is  adjusted  to  keep  the  solution  below  the  boiling-point,  in  order 
not  to  lose  any  of  the  material  through  spattering.  When  the 
solution  is  dry,  the  flame  is  slightly  increased  until  the  entire 
residue  has  become  black.  The  flame  is  then  turned  up.  First 
it  is  increased  about  twice  and  then  the  full  flame  is  turned  up 
(the  entire  heat  of  a  Bunsen  burner)  until  the  residue  in  the  dish 
is  heated  to  redness  for  ten  minutes  after  the  black  residue  has 
become  dry.  Remove  the  flame  and  allow  the  dish  to  cool.  Add 
20  c.c.  of  dilute  hydrochloric  acid  (one  volume  of  concentrated 
hydrochloric  acid  to  four  volumes  of  water)  and  warm  the  solu- 
tion gently  until  the  contents  have  completely  dissolved.  A 
clear,  sparkling  fluid  is  then  obtained.  (The  dissolving  of  the 
precipitate  should  take  about  2  minutes.)  The  solution  is  then 
washed  into  an  Erlenmeyer  flask  of  about  250  c.c.  capacity  with 
distilled  water  and  diluted  to  about  100-150  c.c.  with  cold  dis- 
tilled water.  Add  10  c.c.  of  a  10  per  cent  solution  of  barium 
chloride  drop  by  drop,  and  allow  the  solution  to  stand  for  about 
an  hour.  Shake  and  filter  the  solution  through  a  weighed  Gooch 
crucible  or  an  ash-free  filter  (preferably  a  Gooch  filter).  Wash 
the  precipitate  of  barium  sulphate  with  about  250  c.c.  of  water, 
dry  in  an  air-bath  or  over  a  very  low  flame,  then  ignite,  cool 
and  weigh.  Subtract  the  weight  of  the  Gooch  crucible  from  the 
weight  of  the  crucible  and  the  precipitate  to  obtain  the  weight 
of  the  precipitate.  The  result  thus  obtained  multiplied  by  0.3420 

"Benedict's  reagent  is  composed  of  the  following: 

Crystallized     copper    nitrate     (sulphur-free) 200  grams 

Sodium   or  potassium   chlorate 50  grams 

Distilled    water    to 1000  c.c. 


GENERAL   ANALYSIS  123 

will  give  the  amount  of  sulphur  expressed  as  S03  in  the  urine  used 
in  the  determination.     (See  example  above.) 

Bile. 

When  bile  pigments  are  found  in  urine  it  may  be  regarded  as  a 
pathological  condition.  A  urine  containing  bile  is  yellowish-green 
to  brown  in  color  and  when  shaken  foams  readily,  the  foam  being 
light  yellow  in  color. 

Tests  for  Bile. — The  shaking  of  the  urine  and  observation  of 
the  color  of  the  foam  is  a  valuable  test  for  the  presence  of  bile 
pigments. 

Gmelin's  Test. — Place  1  c.c.  of  concentrated  nitric  acid  in  a 
small  test  tube.  By  means  of  a  pipette  with  a  rubber  bulb  on  one 
end,  having  a  rugged  edge  on  the  other,  allow  an  equal  amount  of 
urine  to  run  gently  down  the  sides  of  the  tube.  The  liquid  should 
stratify  and  if  bile  is  present,  various  colored  rings  (green,  blue, 
violet,  red,  and  reddish-yellow)  will  be  notad  at  the  point  of  contact. 

Smith's  Test. — Place  1  c.c.  of  dilute  tincture  of  iodin  (1  to  10) 
in  a  small  test  tube.  By  means  of  a  pipette  with  a  rubber  bulb  at 
one  end,  having  a  rugged  edge  at  the  other,  allow  an  equal  part  of 
urine  to  run  gently  down  the  sides  of  the  tube.  The  liquids  should 
stratify  and  if  bile  is  present  a  green  ring  will  be  noted  at  the 
point  of  contact. 

Blood. 

Benzidine  Test. — To  about  3  c.c.  of  a  saturated  solution  of  ben- 
zidine  in  glacial  acetic  acid  add  an  equal  volume  of  hydrogen  perox- 
ide (3%)  and  1  or  2  c.c.  of  the  urine  to  be  examined.  Shake  the 
tube  and  in  the  presence  of  blood  a  blue  or  green  color  will  de- 
velop. See  Plate  III  for  the  color  of  the  blood  test.  A  control 
should  always  be  made  using  water  instead  6f  urine.  This»is  a  very 
sensitive  test. 

Guaiac  Test. — Place  about  5  c.c.  of  urine  in  a  test  tube  and  add 
freshly  prepared  alcoholic  solution  of  guaiac  (1  to  60)  until  the 
whole  becomes  turbid.  Then  add  hydrogen  peroxide  or  old  turpen- 
tine until  a  blue  color  appears  (if  blood  is  present).  This  test 


124.  BLOOD    AND    URINE    CHEMISTRY 

gives  positive  results  if  old  or  partly  putrefied  pus  is  present,  even 
before  turpentine  or  peroxide  of  hydrogen  is  added. 

Fresh  pus  gives  positive  results  upon  the  addition  of  hydrogen 
peroxide. 

The  above  test  gives  a  positive  reaction  before  and  after  boiling 
(15  to  20  seconds)  if  blood  is  present.  Pus  does  not  react  after 
boiling. 

Milk,  pus,  saliva,  etc.,  give  positive  reactions  with  the  guaiac  test, 
but  do  not  respond  after  boiling  from  15  to  20  seconds. 


CHAPTER  XXIV. 
MICROSCOPIC  ANALYSIS  OF  URINARY  SEDIMENTS. 

The  value  of  the  microscopic  examination  of  the  urinary  sedi- 
ments of  pathological  urines  is  of  very  great  importance  from  the 
diagnostic  point  of  view.  The  sediments  may  be  divided  into  two 
classes  (a)  organized,  and  (b)  unorganized  sediments. 

Preparation  of  Sediment. — Pour  the  urine  under  examination 
into  a  conical  centrifuge  tube  (Fig.  34J5)  and  centrifuge  (Fig.  34 A] 


Fig.   34 A. — Centrifug 


Fig.   34B. 


al     centrifuge 


for  from  five  to  ten  minutes.  At  the  end  of  this  time,  take  the 
tube  out  of  the  centrifuge  and  introduce  a  pipette  into  the  bottom 
of  the  tube,  a  finger  being  placed  over  the  upper  opening  of  the 
pipette  so  as  not  to  allow  any  urine  to  enter  the  pipette  while  it  is 
being  placed  to  the  bottom  of  the  tube.  When  the  pipette  touches 
the  bottom,  the  finger  is  removed  and  the  deposit  will  flow  up  into, 
the  pipette.  Again  close  the  upper  end  of  the  pipette  and  place  a 
drop  of  the  sediment  on  a  clean  slide.  Then  place  a  cover-glass  over 


126  BLOOD   AND   URINE    CHEMISTRY 

the  sediment.  In  our  laboratories  we  first  examine  the  sediment 
under  the  low  power,  care  being  taken  that  a  good  deal  of  the  light 
is  shut  off.  Casts  are  not  easily  seen  in  the  presence  of  much  light. 
The  sediment  is  then  examined  under  the  high  power  dry  lens.  In 
this  way  any  suspicious  elements  under  the  low  power  may  be 
clearly  seen  under  the  high  power.  When  the  urine  is  to  be  ex- 
amined for  bacteria,  etc.,  the  sediments  are  stained  (see  following 
chapter)  and  examined  under  the  oil-immersion  lens. 

Organized  Sediments.— 

granular. 

hyaline. 

epithelial. 

1.  Casts         j  blood. 

fatty, 
waxy, 
pus. 

2.  Cylindroids. 

3.  Epithelial  cells. 

4.  Leucocytes   (pus  cells). 

5.  Erythrocytes. 

6.  Spermatozoa. 

7.  Urethral  filaments. 

8.  Tissue  debris. 

9.  Animal  parasites. 

10.  Fibrin. 

11.  Microorganisms. 

12.  Foreign  substances  due  to  contamination. 

CASTS. — Casts  are  moulds  of  urinifcrous  tubules.  They  vary 
considerably  in  size,  but  nearly  always  have  parallel  sides  and 
rounded  ends.  The  finding  of  casts  generally  indicates  some  kid- 
ney disorder,  especially  if  accompanied  by  albumin  in  the  urine. 

Granular  Casts. — The  granular  material  generally  consists  of  al- 
bumin, epithelial  cells,  fat,  or  disintegrated  crythrocytes  or  leu- 
cocytes. The  character  of  the  cast  varies  according  to  the  size  and 
nature  of  the  granules,  i.  e.,  finely  granular  casts  or  coarsely  granu- 
lar casts  (Figs.  35  A  and  B). 


MICROSCOPIC    ANALYSIS   OF   URINARY   SEDIMENTS 


127 


Fig.  35 A. — Granular  casts.      (After  Hawk.) 


Fig.  355. — Granular  casts.     (After  Peyer.) 

Hyaline  Casts. — Hyaline  casts  are  pale,  transparent,  homogene- 
ous, and  are  the  most  difficult  form  of  renal  casts  to  detect  under 
the  microscope.  They  are  common  to  all  kidney  disorders  (Fig.  36). 

Epithelial  Casts. — Epithelial  casts  bear  upon  their  surface 
epithelial  cells  and  are  found  in  large  numbers  in  acute  nephritis 
(Figs.  37  A  and  B). 

Blood  Casts. — The  appearance  of  these  casts  in  the  urine  de- 
notes acute  diffuse  nephritis,  acute  congestion  of  the  kidney,  or 
renal  hemorrhage  (Fig.  38a). 


BLOOD    AND    URIXE    CHEMISTRY 


Fig.   36.—  Hyaline  casts.      (After  Hawk.) 


Fig.   37/?.— Kpithelial    casts.      (After    Hawk.) 


MICROSCOPIC    ANALYSIS    OF    URINARY    SEDIMENTS  129 


Fig.  38. — (a)  Blood  casts  (yellow  in  color);   (b)   Pus  casts.     (After  Hawk.) 


Fig.  39. — Fatty  casts.      (After   Peyer.) 

Fatty  Casts. — The  appearance  of  these  casts  denotes  fatty  de- 
generation of  the  kidney  and  are  characteristic  of  subacute  and 
chronic  inflammation  of  the  kidney  (Fig.  39). 

Waxy  Casts. — Waxy  casts  do  not  appear  in  any  particular  form 
of  nephritis,  but  are  rather  common  in  amyloid  disease. 


130 


BLOOD   AND    URINE    CHEMISTRY 


Fig.   4QA. — Cylindroids.      (After   Peyer.) 


l-'ig.  4013. — Cylindroids.      (After  v.   Jaksch.) 

Pus  Casts. — The  surfaces  of  these  casts  are  covered  with  pus  or 
leucocytes.  Pus  casts  are  rare  and  indicate  renal  suppuration 
(Pig.  38b). 

CYLINDROIDS. — Cylindroids  are  often  mistaken  for  casts  but  are 
flat  and  smaller  in  diameter  than  casts.  These  Cylindroids  or  false 


MICROSCOPIC    ANALYSIS   OF    URINARY   SEDIMENTS 


131 


casts  may  become  coated  with  urates  and  be  mistaken  for  granular 
casts.  These,  however,  disappear  on  warming.  Cylindroids  have 
no  particular  significance  because  they  are  found  in  normal  and 
pathological  urine  (Figs.  4.0  A  and  B). 


Fig.  42. — Human  spermatozoa.      (After  Hawk.) 

ERYTHROCYTES. — These  appear  in  the  urine  as  the  normal  bicon- 
cave or  crenated  erythrocyte  (Fig.  41). 

The  pathological  conditions  in  which  erythrocytes  are  found  in 
the  urinary  sediment,  are  as  follows : 

1.  Hemorrhage  of  the  kidney. 

2.  Hemorrhage  of  the  urinary  tract. 


132  BLOOD    AND    URINE    CHEMISTRY 

3.  Hemorrhage  from  congestion. 

4.  Traumatic  hemorrhage. 

5.  Hemorrhagic  diathesis. 

SPERMATOZOA. — Spermatozoa  may  appear  after  coitus  or  in  the 
following  pathological  conditions  (Fig.  42)  : 

1.  Diseases  of  the  genital  organs. 

2.  Nocturnal  emissions. 

3.  Epileptic  and  other  convulsive  attacks. 

4.  They  may  or  may  not  be  motile.     They  have  an  oval  body 
and  a  long,  delicate  tail. 

URETHRAL  FILAMENTS. — These  peculiar  thread-like  bodies  may 
be  found  in  normal  urines,  and  also  in  the  following  pathological 
conditions : 

1.  Acute  gonorrhea. 

2.  Chronic  gonorrhea. 

3.  Urethrorrhea. 

These  filaments  are  generally  macroscopical.  The  first  morning 
urine  is  best  to  be  examined  for  filaments. 

TISSUE  DEBRIS. — The  finding  of  fragments  of  tissue  may  some- 
times throw  some  light  upon  a  pathological  condition.  These  tis- 
sues may  be  found  in  the  following  pathological  conditions: 

1.  Tubercular  affections  of  the  kidney. 

2.  Tubercular  affections  of  the  urinary  tract. 

3.  Tumor  of  the  kidney. 

4.  Tumor  of  the  urinary  tract. 

It  is  necessary,  however,  to  make  a  histological  examination  of 
these  tissue  fragments  before  coming  to  a  final  conclusion  as  to 
their  origin. 

FIBRIN. — Fibrin  clots  arc  occasionally  found  in  the  sediments 
of  urines,  following  hematuria. 

FOREIGN  SUBSTANCES,  DUE  TO  CONTAMINATION. — Care  should  be 
taken  that  such  substances  as  starch  granules,  hair,  fat,  sputum, 
muscle  fibers,  particles  of  food,  fibers  of  silk,  wool,  linen,  etc.,  are 
not  mistaken  for  any  of  the  true  conditions  in  urine. 

Unorganized  Sediments. — 

1.  Ammonium  magnesium  phosphate  (triple  phosphate). 

2.  Calcium  oxalate. 

3.  Calcium  phosphate. 


MICROSCOPIC   ANALYSIS   OF    URINARY    SEDIMENTS 


133 


4.  Calcium  sulphate. 

5.  Calcium  carbonate. 

6.  Uric  acid. 

7.  Urates. 

8.  Cystine. 

9.  Cholesterol. 

10.  Hippuric  acid. 

11.  Leucine,  tyrosine. 


Fig.  43. — "Triple  Phosphate."     (After  Ogden.) 

AMMONIUM  MAGNESIUM  PHOSPHATE  (TRIPLE  PHOSPHATE). — This 
compound  (Fig.  43)  is  characteristic  when  the  urine  has  under- 
gone alkaline  fermentation,  either  before  or  after  being  voided,  and 
crystallized  in  two  forms,  i.  e.,  prisms  and  the  star-shaped  feathery 
crystals.  These  crystals  may  rarely  appear  in  amphoteric  or  faintly 
acid  urines,  provided  the  ammonium  salts  are  present  in  large 
enough  quantity. 


134 


BLOOD   AND    URINE    CHEMISTRY 


The  pathological  conditions  in  which  these  crystals  are  fre- 
quently abundant,  are  as  follows: 

1.  Retention  of  urine  in  the  bladder. 

2.  Paraplegia. 

3.  Chronic  cystitis. 

4.  Enlarged  prostate. 

5.  Chronic  pyelitis. 

CALCIUM  OXALATE. — These  crystals  (Fig.  44)  appear  in  the  uri- 
nary sediment  in  at  least  two  forms,  i.  e.,  octahedral  type  and  the 
dumb-bell  type.  They  may  be  found  in  acid,  neutral  or  alkaline 


Fig. 


ilcium   oxalate   crystals. 


urines,  but  arc  most  frequently  found  in  acid  urines.  Calcium  oxa- 
late crystals  are  found  in  normal  urines,  but  are  increased  in  the 
following  pathological  conditions : 

1.  Diabetes  mellitus. 

2.  Organic  diseases  of  the  liver. 

3.  Diseases  of  the  heart. 

4.  Diseases  of  the  lungs. 

These  crystals  arc  found  in  the  urine  after  the  ingcstion  of  to- 
matoes, garlic,  rhubarb,  oranges,  asparagus,  etc. 

CALCIUM  PHOSPHATE  (STELLAR  PHOSPHATE). — Calcium  phos- 
phate (Fig.  45)  may  occur  in  the  urine  in  the  amorphous,  granu- 
lar or  crystalline  form  and  are  wedge-shaped  and  often  appear  in 
rosette  arrangements.  These  crystals  are  sometimes  mistaken  for 
sodium  urate,  but  may  be  distinguished  from  the  latter  by  dis- 


MICROSCOPIC    ANALYSIS    OF    URINARY    SEDIMENTS 


135 


solving  them  in  acetic  acid.    Acetic  acid  will  readily  dissolve  the 
phosphate,  whereas  the  urate  is  much  less  soluble. 

The  pathological  conditions  in  which  calcium  phosphate  crys- 
tals are  abundant  are  as  follows: 

1.  Retention  of  urine  in  the  bladder. 

2.  Paraplegia. 

3.  Chronic  cystitis. 

4.  Enlarged  prostate. 

5.  Chronic  pyelitis. 


Fig.  45 


Icium  phosphate  crystals. 


CALCIUM  SULPHATE. — These  crystals  (Fig.  46)  are  very  rarely 
seen  and  are  only  found  in  acid  urines.  Calcium  sulphate  crys- 
tals appear  as  long,  thin,  colorless  needles  or  prisms  and  may  be 
mistaken  for  calcium  phosphate.  They  are  readily  distinguished, 
however,  by  the  fact  that  calcium  sulphate  crystals  are  readily 
soluble  in  acetic  acid.  These  crystals  (calcium  sulphate)  are  of 
practically  no  clinical  importance. 

CALCIUM  CARBONATE. — Calcium  carbonate  crystals  (Fig.  47)  al- 
most always  appear  in  alkaline  urine,  but  may  occur  in  ampho- 
teric  or  faintly  acid  urine.  They  very  frequently  appear  in  the 


BLOOD    AND    URINE    CHEMISTRY 


Fig.  46. — Calcium  sulphate.      (After   Ilcnsel  and   Weil.) 


Fig.   47.— Calcium   carbonate   crystals.      (After    Hawk.) 


MICROSCOPIC    ANALYSIS    OF    URINARY    SEDIMENTS 


137 


dumb-bell  shape  and  can  be  differentiated  from  calcium  oxalate, 
inasmuch  as  they  dissolve  in  acetic  acid,  with  the  evolution  of 
carbon  dioxide  gas,  while  calcium  oxalate  remains  unchanged  in 
acetic  acid. 

URIC  ACID. — Uric  acid  crystals  (Fig.  48)  appear  in  acid  urines 
in  the  following  forms: 

1.  AVedge-shaped. 

2.  Dumb-bells. 

3.  Rhombic  prisms. 

4.  Whetstones. 

5.  Prismatic  rosettes. 

6.  Irregular  or  hexagonal  plates. 


Fig.   48.— Uric   aci< 

These  crystals  generally  appear  in  the  urine  colored  brownish- 
red,  although  occasionally  they  can  be  seen  perfectly  colorless. 
The  presence  of  uric  acid  in  the  urinary  sediment  does  not  neces- 
sarily indicate  any  pathological  condition;  neither  does  it  mean 
that  the  uric  acid  content  of  the  urine  is  increased. 

The  pathological  conditions  in  which  uric  acid  is  found  in  the 
sediment,  are  as  follows : 

1.  Gout. 


138 


BLOOD   AND   URINE    CHEMISTRY 


Fig.  49. — Acid   sodium    urate   crystals.      (After   Hawk.) 


Fig.  50. — Ammonium  urate  crystals.     (After  Peyer.) 


MICROSCOPIC   ANALYSIS   OF    URINARY   SEDIMENTS  139 

2.  Acute  febrile  conditions. 

3.  Chronic  interstitial  nephritis. 

URATES. — This  may  appear  as  ammonium,  calcium,  magnesium, 
potassium,  and  sodium  urate.  The  calcium,  magnesium,  potassium, 
and  sodium  urates  appear  in  acid  urines,  while  the  sediment  of 
ammonium  urate  appears  in  neutral,  alkaline,  or  acid  urines. 

Sodium  Urate. — Sodium  urate  (Fig.  49)  may  be  amorphous  or 
crystalline.  When  crystalline  it  appears  in  sheaves  or  clusters 
of  colorless  needles. 

Ammonium  Urate  generally  appears  in  the  burr-like  form  of 
the  "thorn-apple"  (Fig.  50),  which  appears  to  be  balls  with 
spicules  attached. 


Fig.  51. — Cholesterol  crystals.      (After  Hawk.) 

The  pathological  conditions  in  which  urates  may  appear  in  the 
urine  are  somewhat  similar  to  those  of  uric  acid. 

CYSTINE. — Cystine  is  rarely  found  in  urinary  sediments  and 
appears  in  the  form  of  thin,  colorless,  hexagonal  plates.  It  is 
insoluble  in  Avater,  alcohol  and  acetic  acid,  and  soluble  in  minerals, 
hydrochloric  acid,  alkalies,  and  especially  in  ammonia. 

CHOLESTEROL. — Cholesterol  crystals  are  very  rarely  found  in 
urinary  sediments  and  ordinarily  crystallize  in  regular  and  ir- 
regular colorless  plates  which  are  transparent  (Fig.  51).  They 


140 


BLOOD    AND    URINE    CHEMISTRY 


may  occasionally  be  found  as  a  film  on  the  surface  of  the  urine  in- 
stead of  in  the  sediment. 

The  pathological  conditions  in  which  cholesterol  crystals  have 
been  found  in  the  urine,  are  as  follows: 

1.  Cystitis. 

2.  Pyelitis. 

3.  Chyluria. 

4.  Nephritis. 

HIPPURIC  ACID. — This  is  very  rarely  found  in  urinary  sedi- 
ments. The  crystals  appear  as  needles  or  prisms  which  are  gener- 
ally pigmented  in  the  manner  of  uric  acid  crystals. 


Fig.   52. — Hippuric   acid    crystals. 

Hippuric  acid  crystals  (Fig.  52)  are  more  soluble  in  water 
and  ether  than  uric  acid  crystals.  These  crystals  have  practi- 
cally no  clinical  significance. 

LEUCINE  AND  TYROSINE. — These  almost  always  appear  in  the 
urine  together.  They  may  be  in  solution  or  as  a  sediment.  Leu- 
cine  crystallizes  in  characteristic  spherical  masses  and  is  highly 
refractive  (Fig.  53). 

The  pathological  conditions  in  which  leucine  and  tyrosine  have 
been  found,  arc  as  follows: 

1.  Acute  yellow  atrophy  of  the  liver. 

2.  Acute  phosphorous  poisoning. 


MICROSCOPIC    ANALYSIS   OF    URINARY   SEDIMENTS  141 

3.  Cirrhosis  of  the  liver. 

4.  Severe  cases  of  typhoid  fever. 

5.  Severe  cases  of  smallpox. 

6.  Leukemia. 

Urinary  Calculi. — Urinary  calculi  are  solid  masses  of  urinary 
sediment  and  are  formed  in  some  part  of  the  urinary  tract.  The 
smaller  calculi,  termed  sand  or  gravel,  generally  arise  from  the 
kidney  or  the  pelvic  portion  of  the  kidney.  The  large  calculi  are 
generally  formed  in  the  bladder.  Calculi  are  divided  into  two  gen- 
eral classes  [according  to  their  composition,  i.  e.,  simple  (made  up 


Fig.   53. — Crystals  of  impure  leucine.      (After  Ogden.) 

of  a  single  constituent)  and  compound  (made  uip  of  two  or  more 
constituents)]. 

URIC  ACID  AND  URATE  CALCULI. — These  stones  are  always  col- 
ored and  vary  from  a  pale  yellow  to  a  brownish-red. 

PHOSPHATIC  CALCULI. — These  concretions  consist  principally  of 
"triple  phosphate"  and  other  phosphates  of  the  alkaline  earths, 
with  very  frequent  admixtures  of  urates  and  oxalates  (Hawk). 

CALCIUM  OXALATE  CALCULI. — This  is  rather  difficult  to  crush 


142  BLOOD   AND    URINE    CHEMISTRY 

and  generally  occurs  in  two  forms,  the  small  (hemp  seed  calculus) 
and  the  medium  or  the  large  (mulberry  calculus). 
The  following  calculi  are  rarely  found : 

1.  Calcium  carbonate   (extremely  rare). 

2.  Cystine   (rare). 

3.  Xanthine  (more  rare  than  the  cystine  type). 

4.  Urostealith    (extremely   rare). 

5.  Fibrin  (rare). 

6.  Cholesterol  (extremely  rare). 

7.  Indigo  (extremely  rare — only  two  cases  have  been  reported). 

In  examining  the  urinary  calculi  chemically,  the  most  valu- 
able data  are  obtained  by  examining  each  of  the  concentric  lay- 
ers separately.  One  should  saw  the  calculi  through  the  nucleus 
and  separate  the  various  layers.  Enough  material  may  also  be 
obtained  by  scraping  enough  powder  from  each  layer  to  carry 
out  the  examination.  If  the  latter  is  adapted,  the  layers  should 
not  be  separated. 

Murexide  Test. — To  a  small  amount  of  unknown  in  a  small 
evaporating  dish  add  2  to  3  drops  of  concentrated  nitric  acid. 
Evaporate  to  dryness  over  a  water-bath.  If  uric  acid  is  present, 
a  red  or  yellow  residue  remains  which  turns  purplish  red  after 
cooling  the  dish  and  adding  a  drop  of  very  dilute  ammonium 
hydroxide.  The  color  is  due  to  the  formation  of  ammonium  pur- 
purate  or  murexide.  If  potassium  hydroxide  is  used  instead  of 
ammonium  hydroxide  a  purplish  violet  color  due  to  the  pro- 
duction of  the  potassium  salt  is  obtained.  The  color  disappears 
upon  warming;  with  certain  related  bodies  (purinc  bases)  the 
color  persists  under  these  conditions. 

The  following  is  a  scheme  proposed  by  Heller  for  the  chem- 
ical examination  of  urinary  calculi  and  will  be  found  very  use- 
ful in  determining  their  composition.  Reduce  the  calculus  to 
powder  and  proceed  as  follows : 


MICROSCOPIC   ANALYSIS   OF    URINARY    SEDIMENTS  143 

TABLE  XI 
ON  HEATING  THE  POWDER  ON  PLATINUM  FOIL,  IT 


DOES  NOT  BURN 

DOES   BURN 

The  Powder  when  Treated  with 
HC1 

With  Flame 

Without 
Flame 

Does  not  effervesce 

aw* 

S 

si 

.,i 

3*0  g 

C 

The    Powder 
gives    the 
Murexide 

»'r|.n> 

5.  rt 

^  re 

Iri 

Test* 

The    Powder    gently 
heated,  then  treated 
with  HC1 

f|l| 

tf 

re  o_c" 

re  c  r* 

The    Powder 
when    treated 
with  KOH 

The  powder  when 
moistened  with  a 

g"S.e.§ 

1^- 

iff 

gives 

little  KOH 

Elg"  ?5' 

00     " 

1  5'1 

1^3-n    0 

O    ^ 

ro  ^~ 

C*  3 

o  3  P 

fD 

c+ 

2! 

" 

J}> 

5? 

<5     p 

c*  •  — 

^           <D 

Q 

l!t.g 

O.>P  ° 

H 

g"S 

f!  c 

l|l 

IH** 

3 
<K 

3 
O 

^"5-  re  §• 

£•'£•3  3 

? 

3  c-o- 

P  c 

^"re  H 

P 

1" 

if5'" 

£2  i.l 
?  I. 

B 

I 

^H 

b 

I'll 

g.aS' 

1 

1 

O    ?'  >  3 

2."  re  a 

p    rtao 

o5 

P 

in 

r_  c_ 

I  S'^ 

<  ^"1 

P" 

p 

?  *  *'l 

3     Big. 

i 

!'i." 

I"2- 

111 

l&l 

1 
n 

3 

o  j>  p 

S 

o  |5- 

3"  "* 

S.p- 

2. 

*<j  2* 

2.  £-     p 

s:3  g. 

re   ». 

•a. 

?         ^ 

g 

en    £- 

P.O  H 

s  ?* 

er 

cL  Q-  ? 

•      3 

2 

P    3" 

S"  ^ 

p 

I 

c: 

IPS 

If. 

°§    X 

1 

11 

?!! 

o' 

1  1 

i  f.3  3 

§•.  $  5" 

i 

g-' 

Is 

^  s.s 

a  S-l- 

f 

§r 

2§: 

s-g-? 

?  5-2. 

lit! 

"a-a  § 

Calcium 

Calcium 

2. 

3 

d 

1 

i 

5" 

re 

Xanthin 

Ammoni 

n 

2. 

p    «•       TS 

P^  ^, 

_. 

._ 

?v 

re 

c    * 

HI 

-5-     S.cT 

2. 

X 

P 

tr- 

3 

"'*        3- 

39 

P" 

r 

d 

il 

si 

JT 

g 

re" 

? 

P  3"    - 

ao 

?  a. 

<<J  3 

5 

i 

*See  page  142  for  murexide  test. 


CHAPTER  XXV. 

THE  STAINING  OF  BACTERIA  IN  URINE. 

Freshly  voided  urine  from  normal  persons  is  free  from  bac- 
teria, but  on  standing  it  becomes  loaded  with  saprophytic  organ- 
isms. Fungi  are  prone  to  develop  quickly  in  diabetic  urine. 
Actinomycosis  of  the  genitourinary  tract  embodies  the  finding  of 
the  actinomyces  in  the  urine.  In  general  aspergillosis,  the  As- 
pergillus  fumigatus  appears  in  the  urine.  Of  the  bacteria  to  be 
met  with  in  urine  in  pathological  states,  we  must  consider  the 
Bacillus  typhosus  wrhich  is  found  in  at  least  thirty  per  cent  of 
all  cases  of  typhoid  fever.  Again  we  may  find  the  streptococcus, 
the  staphylococcus,  the  gonococcus,  and  the  glanders  bacillus. 
These  are,  of  course,  met  with  in  specific  infections.  In  nephritis 
of  children  we  are  apt  to  find  the  streptococcus  and  the  Bacillus 
coli  communis.  The  latter  organism  is  frequently  found  in  the 
urine  from  cases  of  acute  cystitis  and  pyelitis.  The  Staphylococcus 
pyogenes  albus  and  aureus  are  seen  in  cases  of  acute  cystitis  and, 
occasionally  the  Bacillus  pyocyaneus. 

The  organism  that  is  possibly  the  most  important  one  from 
the  standpoint  of  diagnosis  of  urinary  sediment  is  the  Bacillus 
tuberculosis.  Tuberculosis  of  the  genitourinary  tract  is  not  an 
uncommon  condition.  Thanks  to  the  exceedingly  careful  work 
of  the  modern  urologist,  this  disease  is  frequently  recognized  in 
time  to  save  life,  inasmuch  as  the  Great  White  plague  in  this 
locality  is,  almost  strictly  speaking,  a  surgical  condition.  Prompt 
diagnosis  and  prompt  extirpation  of  a  tuberculous  kidney  will 
often  result  in  a  success.  The  diagnosis  of  tuberculosis  from 
the  urinary  sediment  is,  therefore,  extremely  important.  Whether 
the  specimen  represents  a  cathcterized  ureteral  specimen  or  a 
catheterized  bladder  specimen,  it  should  be  treated  as  follows: 

After  obtaining  the  specimen  either  through  a  sterile  ureteral  or 
sterile  urcthral  catheter,  rapidly  ccntrifugalize  the  urine.  Then 
pour  off  the  supernatant  fluid  and  fill  the  centrifuge  tube  with 
sterile  distilled  water,  shake  to  wash  out  the  urinary  salts  which 

ill 


THE    STAINING   OF    BACTERIA    IN    URINE  145 

interfere  with  staining,  and  centrifugalize  again.  This  may  be 
repeated,  rejecting  the  supernatant  fluid.  Spread  the  sediment 
upon  a  clean  glass  slide  by  means  of  a  sterile  pipette  or  platinum 
loop,  allow  to  dry  in  the  air,  and  then  fix  by  passing  through 
the  flame  three  times.  Stain  the  specimen  just  as  we  stain  spu- 
tum for  the  Bacillus  tuberculosis,  i.  e.,  steam  for  three  minutes 
with  carbol-f uchsin ;  then  wash  off  the  excess  stain  with  water  and 
decolorize  and  counterstain  with  Gabbet's  solution.  (Gabbet's  so- 
lution is  made  by  mixing  2  grams  of  methyl ene  blue  with  100  c.c. 
of  25%  sulphuric  acid.)  Dip  the  slide  but  one  minute  in  this 
solution  and  rapidly  wash  off  with  water,  dry,  and  examine. 

If  acid-fast  organisms  are  present,  it  is  well  to  bear  in  mind 
that  not  only  the  Bacillus  tuberculosis  but  also  the  smegma  bacil- 
lus is  acid-fast.  In  other  words,  microscopic  finding  of  an  acid- 
fast  bacillus  in  urine  is  not  positive  proof  of  tuberculosis.  We 
do  not  believe  that  the  differentiation  may  be  made  by  means  of 
the  microscope  alone,  even  though  some  advise  the  expedient 
of  decolorization  with  alcohol  or  with  acid  for  a  longer  time  (the 
smegma  bacillus  does  not  resist  acid  as  long  as  the  tubercle  bacil- 
lus). Rather  would  we  recommend  in  all  cases  the  use  of  the 
guinea  pig  in  making  the  diagnosis  of  renal  tuberculosis.  This 
test  is  carried  out  by  inoculating  \vith  the  urinary  sediment,  two 
guinea  pigs  that  are  tuberculosis-free,  as  determined  by  the  tu- 
berculin test, — one  intraperitoneally,  the  other  directly  in  the 
mass  of  inguinal  glands.  They  are  kept  under  observation  for 
three  weeks.  If,  during  this  time,  they  have  not  lost  weight  or 
developed  symptoms,  they  usually  show  no  tuberculosis.  How- 
ever, in  the  event  that  the  guinea  pigs  do  not  die  within  this  time, 
they  should  be  kept  three  weeks  longer  and  then  should  be  anes- 
thetized to  death  and  examined  closely  for  signs  of  tuberculosis. 

In  case  there  is  occasion  to  examine  urinary  sediment  for  sim- 
ple organisms  such  as  staphylococci,  etc.,  we  would  recommend 
the  following  procedure :  Treat  the  sediment  as  before,  wash- 
ing out  the  urinary  salts  with  distilled  and  sterile  water.  Smear 
the  sediment  and  dry  on  slides.  Fix  in  flame  and  stain  for  one 
minute  with  Ro.ux's  blue  which  we  have  found  to  be  the  best 
routine  stain  for  bacteria.  Roux's  blue  is  made  as  follows: 


146  BLOOD   AND   URINE    CHEMISTRY 

Solution  A. 

Violet    dahlia  1  gin. 

Absolute  alcohol  10  gms. 

Distilled  water                q.s.  for  100  gms. 

Solution  B. 

Methyl   green  2  gms. 

Absolute  alcohol  20  gms. 

Distilled  water  q.s.  200  gms. 

Prepare  each  solution  separately  by  rubbing  up  the  dye 
with  the  alcohol  in  a  mortar  and  add  the  water  gradually. 
Let  the  mixture  stand  for  24  hours  in  a  bottle.  Then  mix 
the  two  solutions,  filter  and  store  in  a  well-stoppered  bottle. 

After  staining  with  the  above  one  minute,  wash  in  water,  dry, 
and  examine.  This  makes  a  beautiful  stain  for  ordinary  purposes 
and  in  our  experience  is  better  than  the  much  used  Loeffler  stain. 

In  cases  where  Gram  staining  is  necessary,  for  instance,  in  at- 
tempting to  differentiate  gonococci  from  Gram-positive  organisms, 
we  would  recommend  the  following  modification  of  the  usual  Gram 
method.  This  possesses  the  advantage  of  a  permanent  and  re- 
liable primary  stain,  thereby  being  superior  to  the  aniline-oil- 
gentian-violet  mixture  that  must  be  made  up  fresh  every  time  it 
is  used.  Spread  the  urinary  sediment,  dry  in  the  air  and  fix  in 
the  flame. 

1.  Stain  for  30  to  60  seconds  with  carbol-gcntian  violet,  which 
is  made  as  follows: 

Gentian  violet  1  gm. 

Carbolic  acid  crystals  2  gms. 

Absolute  alcohol  10  c.c. 

Distilled  water  100  c.c. 

Rub  up  the  gentian  violet  and  the  alcohol  in  a  glass  mor- 
tar, add  the  carbolic  acid  and  mix;  add  two-thirds  of  the 
water,  stirring  all  the  time;  pour  the  mixture  in  a  bottle, 
then  rinse  out  the  mortar  with  the  rest  of  the  water  and 
add  it  to  the  mixture  in  the  bottle.  Leave  for  24  hours  and 
filter  into  a  clean  glass-stoppered  bottle. 

2.  Blot  up  the  excess  of  stain   (but  do  not  wash),  drop  two 
or  three  large  drops  of  Gram's  solution  of  iodine  (iodine  1  gram., 
potassium  iodide  2  grams,  distilled  water  300  c.c.)  on  the  smear, 
and  allow  it  to  stain  20  to  30  seconds. 


THE   STAINING   OF    BACTERIA   IN    URINE  147 

3.  Wash  in  water  and  dry. 

4.  Pour  absolute  alcohol  over  the  film  a  drop  at  a  time  until 
no  more  violet  stain  comes  away — usually  30  seconds. 

5.  Wash    in  water  quickly. 

6.  Counterstain  for  one  minute  with  an  aqueous  solution  of 
saffranin. 

7.  Wash  in  water,  dry  and  examine.     Gram-positive  organisms 
are  stained  a  deep  violet  and  Gram-negative  organisms  a  delicate 
light  pinkish  or  safranin  color. 


CHAPTER  XXVII. 

DESCRIPTION  OF  THE  COLORIMETER 

The  methods  for  blood  and  urine  determinations  just  described 
entail  the  use  of  an  instrument  known  as  the  colorimeter.  The 
two  best  known  instruments  are  the  Duboscq  and  the  Hellige. 
Both  these  instruments  were  formerly  made  abroad  and  were 
difficult  to  obtain  during  the  Great  War  period.  The  Hellige 
is  our  instrument  of  choice  with  these  methods  owing  to  its  com- 
parative inexpensiveness  and  because  much  smaller  quantities 
of  standard  solutions  are  needed  in  using  it,  a  consideration  of 
much  importance  in  these  times  of  high  price  and  scarcity  of 
chemicals.  The  tables  found  in  this  work  are  based  upon  com- 
putations with  the  Hellige  instrument.  The  Hellige  instrument 
is  now  made  in  this  country  under  license  issued  to  the  Leitz 
Company.  The  Duboscq  is,  of  course,  the  instrument  of  greatest 
accuracy,  and  fortunately  at  this  time  it  is  possible  to  obtain  this 
instrument  again.  We  will  describe  it  after  the  Hellige  instru- 
ment. So  far  as  other  colorimeters  now  on  the  market  are  con- 
cerned, the  Kuttner-Leitz,  Myers,  etc.,  we  are  inclined  to  be 
dubious  as  to  their  usefulness  in  the  work  of  this  kind.  The  dis- 
advantages of  the  former  instrument  are  the  use  of  wedges  or 
tubes  containing  permanent  colors  as  standards.  The  Mecca  of 
that  success  that  comes  from  the  greatest  accuracy  is  in  the  rapid 
making  and  mixing  of  the  standard  solutions  at  the  same  time  and 
under  the  same  conditions  as  the  unknown.  Standard  solutions 
made  in  this  way  and  used  in  the  colorimeter  are  necessarily  the 
best.  The  standards  for  sugar,  i.e.,  picramic  acid,  and  the  stan- 
dard for  the  functional  kidney  test  of  Geraghty  and  Rowntree, 
keep  some  months,  but  they  come  within  the  scope  of  the  above 
requirements.  We  would  therefore  exclude  from  consideration 
all  colorimeters  using  wedges  and  tubes  filled  with  solutions 
which  are  not  of  the  same  chemical  structure  and  composition  as 
the  unknown.  So  far  as  the  colorimeter  of  Myers  is  concerned, 
it  is  not  to  be  recommended,  owing  to  the  rapid  changes  that 

148 


DESCRIPTION    OF    THE    COLORIMETER 


149 


take  place  in  the  standard  and  the  unknown  in  the  rather  time- 
consuming  process  dilution. 

The  following  description  and  drawings  of  the  Hellige  instru- 
ment are  taken  from  the  treatise  by  Prof.  Autenrieth  and  Prof. 
Koenigsberger,  both  of  Freiburg,  published  by  F.  Hellige  & 
Company. 

This  apparatus  is  available  for  color  measurements  of  every 
kind  and  consists  of  a  wooden  case  the  back  and  front  of  which 
are  in  the  form  of  removable  slides,  as  shown  in  Fig.  54. 


Fig.   54. — Representation   of   Hellige   colorimeter. 

The  front  slide  (F)  is  fitted  on  its  outer  side  with  a  slit  plate, 
which  forms  the  observation  window  and  behind  this  on  the  in- 
ner side  is  a  Helmholtz  Double  Plate  (DP}.  The  latter  is  mov- 
able and  is  held  between  two  spring  clips  (KL),  from  which  it  can 
be  readily  released  for  the  purpose  of  cleaning.  The  back  (Sell) 
can  be  moved  up  and  down  in  a  convenient  manner  by  means 
of  the  rack  and  pinion  mechanism  (Z),  seen  on  the  right.  The 
back  plate  has  attached  to  it  the  most  essential  part  of  the  colori- 


150 


BLOOD   AND    URINE    CHEMISTRY 


meter,  which  is  a  hollow  glass  wedge  filled  with  a  standard  solu- 
tion. On  the  left  side  the  plate  is  fitted  with  a  scale  ($)  which 
travels  along  a  pointer  (d).  The  open  middle  portion  of  the 
back  between  the  rack  and  the  scale  is  covered  by  a  ground 
glass  plate  (M),  which  is  held  in  position  by  a  catch  (7i)  at  the 
top  and  may  thus  be  removed  at  any  time  without  trouble. 

Near  the  top  the  sliding  back  is  fitted  with  a  wedge  holder 
(KH)  and  at  a  corresponding  point  at  the  bottom  of  the  slide  it  is 
fitted  with  a  grooved  wooden  block  (B).  To  adjust  the  wedges 


Kig.  55. — Representation  of  Hellige  colorimeter. 

(K)  in  their  proper  position,  the  set  screw  (a]  which  forms  part 
of  the  wedge  holder  should  in  the  first  instance  be  turned  coun- 
ter-clockwise, and  the  fitting  with  the  bracket  attachment  pressed 
firmly  upwards.  The  sealed  end  of  the  wedge  should  then  be 
passed  through  the  hole  in  the  bracket  attachment  and  the  wedge 
let  down  into  the  fitting  and  the  set  screw  turned  clockwise,  so 
as  to  clamp  the  holder  firmly.  The  wedge  should  always  be  in- 
serted with  its  right  angle  and  the  rectangular  vertical  face  turned 
towards  the  observer. 

The  small  glass  trough    (C)    receives  the  liquid  to  be  tested. 
It  slides  into  the  trough  holder    (TH),  whereby  it  is  attached 


DESCRIPTION    OF    THE    COLORIMETER 


151 


to  the  left  side  of  the  colorimeter.  To  set  the  instrument 
for  taking  a  reading,  the  back  of  the  colorimeter  case  together 
with  the  wedge  should  be  moved  up  or  down  bodily  with  the  aid 
of  the  pinion  (T)  and  the  reading  should  be  taken  when  the  color 
intensity  due  to  the  thickness  of  the  standard  fluid  equals  that 
of  the  solution  being  tested. 

To  read  the  result  the  scale  division  indicated  by  the  pointer 
should  be  noted,  and  the  corresponding  figure  read  on  the^ordi- 


Fig.  56. — Representation  of  Hellige  colorimeter. 

nates  of  the  calibration  curve  of  the  standard  wedge ;  and  from  the 
coordinate  abscissa  the  amount  of  substance  contained  in  a  given 
quantity  of  fluid,  as  noted  in  the  curve  table,  can  be  determined. 
The  wedge  should  always  travel  in  close  proximity  to  the 
trough,  which  is  generally  ensured  without  difficulty  by  applying 
a  gentle  pressure  from  the  side.  There  should  never  be  a  bright 
gap  between  the  two  fields  under  comparison,  which  should  merely 
be  separated  by  a  fine  line.  All  glass  fittings,  such  as  the  double 


152 


BLOOD    AND    URINE    CHEMISTRY 


plate,  trough,  wedge,  and  ground  glass  plate  should  be  dry  on 
the  outside  and  carefully  freed  from  particles  of  dust. 

To  examine  solutions  which  are  so  faintly  colored  as  barely 
to  exhibit  any  tint  when  viewed  in  the  ordinary  trough,  such  as 
when  determining  very  small  quantities  of  ammonia  with  Ness- 
ler's  reagent,  it  is  necessary  to  equip  the  colorimeter  with  a  long 
trough  shown  in  Fig.  55.  The  latter  is  supplied  in  two  forms, 
either  with  a  drop-in  cover  (/,  Fig.  55)  or  a  glass  stopper  (g, 
Fig.  55).  This  trough  is  held  in  position  within  horizontal  slides, 


Fig.  57. — Representation   of  Ilellige  colorimeter. 

as  shown  in  Fig.  57.  To  put  it  in,  the  ground  glass  back  should 
be  removed,  the  wedge  put  in  position,  and  the  back  pushed  into 
the  slide  frame.  The  long  trough  with  its  projecting  back  should 
be  passed  through  the  opening  at  the  back  of  the  colorimeter  into 
the  horizontal  trough  holder  referred  to.  When  the  long  trough 
is  being  used  the  colorimeter  requires  to  be  fitted  at  the  back  with 
a  light-screening  attachment  closed  at  the  end  by  a  ground-glass 


DESCRIPTION    OF    THE    COLORIMETER 


153 


plate  so  as  to  encase  that  part  of  the  trough  which  projects  from 
the  apparatus. 

For  determining  the  proportion  of  iron  present  in  a  solution, 
the  apparatus  is  supplied  with  a  glass  stoppered  trough,  as  shown 
at  e  in  Fig.  55,  so  as  to  obviate  the  evaporation  of  the  ether  during 
the  observation. 

The  various  troughs  may  be  cleaned  by  rinsing  them  out  with 
a  little  diluted  hydrochloric  acid,  after  which  they  should  be 
rinsed  in  rotation  with  water,  alcohol,  and  ether,  and  finally 
dried. 

For  the  success  of  the  colorimetric  method  it  is  essential  that  all 
solutions  so  tested  should  be  absolutely  clear.  All  traces  of  cloudi- 


Fig.   58. — Optical  arrangement   of  window  of  colorimeter. 

ness  or,  what  is  still  more  objectionable,  any  precipitate  that  may 
be  present,  should  be  removed  by  filtration.  The  presence  of  either 
is  liable  to  falsify  completely  the  adjustment  for  equality  of  color 
intensity. 

To  obtain  a  reliable  reading  it  is  best  to  use  diffused  daylight, 
but  it  should  not  be  too  bright.  The  apparatus  should  be  placed 
over  against  a  well  lighted  background,  such  as  a  white  wall, 
and  the  eye  should  be  applied  to  it  within  the  distance  of  distinct 
vision,  i.  e.,  nearer  than  ten  inches.  After  a  little  practice  use 
may  be  made  of  artificial  light,  but  in  many  cases  the  turning 
point  in  the  intensities  under  comparison  is  not  so  well  marked  as 
when  diffuse  daylight  is  used. 

To  exclude  any  accidental  light,  which  may  interfere  with  the 
accuracy  of  the  reading,  a  screening  tube  about  six  inches  long 


154  BLOOD   AND    URINE    CHEMISTRY 

can  be  supplied,  if  desired,  for  attachment  to  the  observation 
window  on  the  front  slide,  which  can  for  this  purpose  be  fitted 
with  a  brass  socket. 

The  instrument  described '  above  is  adapted  for  any  species 
of  analysis  by  the  method  of  color  comparison,  and  may  within 
its  proper  limits  be  described  as  a  universal  instrument,  since  by 
a  simple  interchange  of  standardized  wedges  it  can  be  rendered 
available  for  any  determination  that  may  present  itself.  It  goes 
without  saying  that  every  species  of  analysis  requires  the  use  of 
a  specially  standardized  wedge. 

Special  sets  of  standardized  wedges  are  supplied  for  various 
purposes;  for  instance,  tlie  analysis  of  drinking  water,  rare  metals, 
etc.  It  is  especially  important  to  note  that  empty  wedges  with 
glass  stoppers  can  be  supplied,  if  ordered,  so  that  the  calibration 
of  new  standards  for  special  colorimetric  determinations  can  bo 
undertaken  by  the  analyst  himself. 

The  Duboscq  Colorimeter 

The  original  Duboscq  instrument  is  made  in  Prance  and  sup- 
plies from  that  country  are  now  coming  into  the  United  States 
and  will  shortly  be  obtainable.  The  instrument  known  as  the 
"Duboscq-Leitz"  colorimeter  is  manufactured  in  this  country 
by  E.  Leitz  of  New  York  in  exact  accordance  with  the  original 
French  pattern  and  is  guaranteed  to  offer  identical  results. 
Cut  of  same  is  presented  in  Fig.  59. 

The  Duboscq-Leitz  colorimeter  presents  to  the  single  eye  simul- 
taneously two  areas  in  contact,  illuminated  by  the  same  source 
of  light  that  traverses  the  columns  of  the  liquids  to  be  com- 
pared. The  Duboscq  is  also  made  in  this  country  now  by  Bausch 
&  Lomb. 

The  colorimeter  consists  of  the  following  parts: 

1.  The  Stand,  A. 

2.  Prism   Housing,   containing  two   cemented   prisms,   B. 

3.  Glass  cylinders,  C. 

4.  Solid  glass  plungers,  D. 

5.  Eyepiece,  E. 


DESCRIPTION    OF    THE    COLORIMETER- 


155 


6.  Rack  and  Pinion   for  perpendicular  motion  of  glass 
cylinders,  F. 

7.  Mirror,  G. 

8.  Protection  guard,  H. 

The  mirror  (G)  supported  by  the.  base  of  the  instrument,  has 
two  surfaces,  one  clear  for  direct  reflected  light,  the  other  opaque 
for  diffused  light, 


Fig.  59. — Duboscq  colorimeter. 

The  liquids  to  be  compared,  viz.,  ''Known"  and  "Unknown," 
are  contained  in  the  two  glass  cylinders  (C,  C),  the  bottoms  of 
which  consist  of  piano-parallel  glass  plates. 

So  as  to  vary  at  will  the  thickness  of  the  two  columns  of  liquids, 
through  which  the  light  passes,  two  glass  plungers  (D,  D,)  are 
provided,  which  reach  into  the  glass  cylinders  (C,  C).  These 


156  BLOOD   AND    URINE    CHEMISTRY 

plungers  are  of  solid  glass,  their  upper  and  lower  surfaces  being 
piano-parallel. 

These  plungers  are  moved  along  their  perpendicular  axes  by  a 
rack  and  pinion  motion  (F)  and  their  lower  surfaces  can  be 
brought  into  contact  with  the  glass  bottom  of  the  cylinders  (C,  C) 
at  the  zero  point  of  the  scale. 

This  scale  consists  of  a  graduation  in  millimeters  and  a  vernier 
10  mm.  :10,  which  permits  measuring  with  precision  the  extent 
of  the  displacement  of  the  cylinders  (C,  C).  The  Duboscq-Leitz 
colorimeter  claims  an  advantage  over  other  colorimeters  in  that 
it  carries  an  adjustable  vernier  enabling  the  laboratory  worker 
to  adjust  the  zero  point  in  case  parts,  plungers  or  cylinders,  are 
replaced  on  account  of  breakage,  when  these  parts  do  not  ex- 
actly conform  in  dimensions  to  those  originally  supplied  with 
the  instrument.  Two  cemented  prisms  (B)  in  housing,  are 
mounted  above  the  two  plungers  (D,  D)  which  receive  the  pencils 
of  light  coming  from  the  plungers  and  bring  these  two  pencils 
of  rays  in  contact  by  two  interior  reflections.  These  two  pencils 
of  light  brought  in  contact  within  the  prisms  (B)  are  observed 
through  the  eyepiece  (E)  situated  above  the  prism  housing.  The 
colorimeter  can  be  illuminated  either  by  daylight,  which  is  pref- 
erable, or  by  artificial  light,  using  blue  glass. 

Directions  for  Using  the  Duboscq.— One  of  the  glass  cylinders 
(C}  contains  the  standard  solution  called  the  "Known"  and  the 
other  the  liquid  to  be  studied  called  the  "Unknown."  Any  de- 
sired thickness  of  the  solution  can  be  viewed  between  the  bottom 
of  the  cylinders  and  the  base  of  the  plungers  (D,  Z>)  by  moving 
the  cylinders  within  their  perpendicular  axes,  using  the  rack  and 
pinion  (F).  For  colorimetric  comparison,  first  regulate  the  mir- 
ror (G)  by  looking  through  the  eyepiece  (E),  focus  the  latter 
by  its  mounting,  turn  the  mirror  so  that  the  two  halves  of  the 
field  of  vision  appear  of  equal  intensity.  To  accomplish  this 
properly  the  cups  must  be  empty  and  completely  clean.  Then 
pour  the  solutions  into  the  cylinders  (C,  C).  The  cylinder  con- 
taining the  known  solution  or  standard  is  then  lowered  so  as  to 
obtain  a  specific  thickness  of  this  solution  between  the  bottom 
of  the  cylinder  (C)  and  the  base  of  the  plunger  (D).  The  half 
of  the  field  of  vision  representing  the  standard  solution  will 
become  darker,  while  the  color  in  the  other  cylinder  holding  the 


DESCRIPTION    OF    THE    COLORIMETER  157 

unknown  will  appear  of  a  different  color.  By  raising  or  lower- 
ing the  cylinder  of  the  Unknown,  the  two  halves  of  the  field 
can  be  easily  brought  to  an  identical  intensity.  When  this  is 
accomplished,  it  is  then  only  necessary  to  read  on  the  scale  the 
heights  of  the  two  layers  of  liquid,  possessing  an  equal  power  of 
absorption.  The  difference  between  the  two  scale  readings,  con- 
trolling the  known  and  the  unknown  solutions,  represents  the 
coloring  matter  contained  in  the  unknown  proportions  to  the 
coloring  matter  as  it  is  contained  in  the  known. 

Example  1. — If  the  readings  at  the  scale  are  for  Known  solu- 
tion =  20,  unknown  =  10,  make  the  computation  as  follows. 

20 

— =  2.0,  i.  e.,  the  color  of  the  standard  or  known  equals  1  and 

that  of  the  unknown  2.  Therefore,  if  the  known  or  standard  con- 
tained 4  c.c.  of  coloring  matter  per  100  e.c.,  then  the  Unknown 
would  contain  4  x  2,  or  8  c.c.  to  100  c.c. 

If  the  standard  solution  is  too  dark  when  comparing  with  the 
Unknown  making  it  impossible  to  equalize  the  luminous  intensity  of 
the  two  halves  of  the  field  (since  the  thickness  of  the  layer  to  be 
compared  cannot  be  increased  beyond  the  sliding  motion  of  the 
cylinder)  then  the  layer  of  the  standard  solution  has  to  be  re- 
duced by  raising  the  cylinder  until  a  uniform  illumination  (in- 
tensity) of  the  field  is  obtained.  In  this  case  the  proportion  of 
intensity  of  the  two  solutions  represents  a  reversed  problem  and 
a  different  method  of  computation  has  to  be  followed. 

Example  2. — If  the  readings  at  the  scale  are  for  standard  or 
Known  solution  ==  15,  and  the  Unknown  =  3.0,  then  the  computa- 
tion is  made  as  follows:  —  =  0.5.  The  color  of  the  standard 
oO 

equals  1,  and  that  of  the  Unknown  0.5.  If  the  standard  solution 
contains  4  c.c.  of  coloring  matter  to  the  100  c.c.,  then  the  Un- 
known would  contain  4  x  0.5  or  2  c.c.  per  100  c.c. 

Bock-Benedict  Colorimeter 

An  American-made  colorimeter  has  recently  been  put  upon 
the  market,  according  to  the  plans  of  Joseph  C.  Bock  and  Stan- 
ley R.  Benedict  of  the  Department  of  Chemistry,  Cornell  Uni- 
versity Medical  College,  New  York  (Jour.  Biol.  Chem.,  August 
1918).  It  is  manufactured  by  the  C.  M.  Sorenson  Company,  177 


158 


BLOOD   AND   URINE    CHEMISTRY 


East  87th  St.,  New  York  City.  It  is  a  comparatively  inexpensive 
instrument  and  gives  excellent  results,  fully  equal  to  those  of 
the  Hellige  or  the  Duboscq.  Fig.  60  gives  a  cross  section  of  this 
instrument. 


Fig.   60. — The  Bock-Benedict  colorimeter. 

Key    to    Fig.    A.— A,    Lens.  E,    Eye-piece.      IIM,    Half   size    mirror.      FM,    Full    size 

mirror.      S,    Cell    for    standard  solution.      P,    Plunger.      C,    Cup    for    unknown    solution. 

R,   Large    reflector.      ST,    Stage  for    holding   cup.      T,    Thumb   screw    moving   stage   up    or 
down.     SC,   Set  screw. 


Key  to  Fig.  B.— FM,  Fu 
E,  Eye-piece. 


nirror.     IIM,  Half  size  mirror.     F,   Side  by  side   field. 


Pig.  60A  shows  the  path  of  the  reflected  two  beams  of  light 
and  Fig.  GOB  shows  the  mirror  arrangement,  through  which  a 
perfect  flat  "side  by  side"  field  is  obtained. 

Directions.— Run  cup  C  up  until  the  bottom  of  cup  and  bottom  of 
plunger  P  meet,  now  see,  if  the  vernier  on  scale  reads  zero.  Should 
it  not  read  zero,  run  the  cup  down  again  and  then  loosen  the  set 
screw  SC.  Then  pull  plunger  down  a  few  millimeters  and  run  the 
cup  slowly  up  again,  while  closely  watching  the  vernier  and  scale. 
As  soon  as  the  vernier  has  met  the  "Zero  Point"  tighten  the  set 
screw  of  the  plunger  and  the  instrument  is  properly  set.  It  is 


DESCRIPTION   OF    THE    COLORIMETER  159 

always  advisable  whenever  work  is  started  or  a  new  cup  is  used 
to  check  the  instrument  in  the  above  manner  to  insure  absolute 
accuracy. 

In  order  to-  use  the  colorimeter,  put  empty  dry  cell  in  place, 
put  on  housing,  and  the  cup  at  a  distance  so  as  to  be  equal  to  cell 
diameter.  Looking  through  the  telescope,  move  the  large  re- 
flector until  both  fields  are  exactly  equal.  Now  put  standard 
solution  in  the  cell  and  unknown  solution  in  the  cup.  Move  cup 
slowly  up  and  doAvn  by  means  of  pinion  wheel  until  fields  appear 
even.  Bead  scale.  By  turning  the  cell  90°  another  depth  of 
standard  color  is  obtained.  All  readings  must  be  taken  with 
housing  in  place. 


PART  III 

BLOOD  FINDINGS  AND  THEIR 
INTERPRETATION 

CHAPTER  XXVII 
BLOOD  SUGAR. 

What  is  the  significance  of  the  finding  of  an  undue  amount  of 
sugar  in  blood  as  compared  to  the  finding  of  an  undue  amount 
of  sugar  in  urine?  The  true  condition  of  the  patient  so  far  as 
carbohydrate  metabolism  is  concerned  may  better  be  seen  by  an 
estimation  of  the  amount  of  blood  sugar  that  he  will  show,  rather 
than  by  the  degree  of  glycosuria.  As  a  result  of  the  data  which 
have  been  obtained  by  following  out  these  microchemical  methods, 
we  know  that  a  hyperglycemia  may  exist  without  any  glycosuria. 
Again  we  have  glycosuria  without  hyperglycemia.  The  appear- 
ance of  sugar  in  the  urine  in  cases  of  diabetes  mellitus,  it  is  as- 
sumed, is  merely  a  matter  of  the  threshold  point,  as  it  were,  hav- 
ing been  passed.  The  threshold  point,  that  is,  the  time  when  the 
sugar  increase  in  the  blood  is  accompanied  by  a  pouring  out  of 
sugar  in  the  urine,  is  a  matter  of  debate.  Hammann  and  Hirsch- 
man,1  at  the  1916  meeting  of  the  American  Society  for  the  Ad- 
vancement of  Clinical  Investigation,  reported  from  a  study  of  50 
cases  that  if  the  blood  sugar  was  not  above  0.17  per  cent,  sugar 
failed  to  appear  in  the  urine,  but  that  \vhen  it  reached  0.18  per 
cent  or  more,  there  was  a  development  of  glycosuria.  Foster,2  at 
the  same  meeting,  found  the  renal  threshold  of  permeability  to  lie 
between  0.149  and  0.164  per  cent,  basing  his  observations  upon 
studies  made  with  patients  after  undergoing  ether  narcosis. 
Hammann  and  Ilirschman3  in  their  further  studies  on  blood 
sugar  state  that  in  normal  persons  the  renal  threshold  is  not  a 

Mlammann   and   Ilirschman:     Joslin    (quoted)    Diabetes   Mellitus,    19K>    !>•    74. 

Foster,  N.15.:  loc.  cit. 

••'Hammann   and   Ilirschman:     Arch.   Int.   Med.,   1917,  v,   809. 

160 


BLOOD   SUGAR  161 

constant  factor,  but  is  usually  above  0.17  per  cent  of  blood  sugar 
concentration,  and  in  a  few  instances  where  it  could  be  accurately 
determined  it  lay  between  0.17  and  0.18  per  cent.  In  two  in- 
stances, and  we  have  since  found  two  more,  the  renal  threshold 
was  jnuch  lower,  namely,  below  0.14  per  cent,  and  these  persons 
may  have  glycosuria  after  carbohydrate  feeding  even  though  the 
blood  sugar  curve  is  within  the  normal  reaction  limits.  They 
predict  that  many  otherwise  normal  persons  with  "occasional 
glycosuria  will  be  found  on  more  careful  observation  to  belong  to 
this  interesting  group  with  low  renal  threshold.  The  relation 
of  this  group  to  renal  diabetes  is  also  obvious.  Again,  Hammann 
and  Hirschman  refer  to  the  fact  that  in  nephritis  the  renal 
threshold  point  is  often  above  0.20.  It  has  been  generally  known 
that  there  is  a  high  threshold  point  in  nephritis,  but  they  call 
attention  to  the  fact  that  without  any  known  cause,  some  nephrit- 
ics  have  a  high  threshold  point  and  others  a  low  point.  One  of 
their  cases  with  marked  hypertension  and  a  phthalein  output 
of  33  per  cent  had  a  normal  threshold.  Another  with  a  blood 
pressure  well  above  200  mg.  Hg.,  and  a  phthalein  output  of  only 
15  per  cent,  had  a  low  threshold  point,  namely,  in  the  neighbor- 
hood of  0.15  per  cent.  In  diabetes  they  state  that  very  interest- 
ing variations  are  discovered.  In  the  mild  cases  the  renal 
threshold  is  at  the  normal  level,  but  in  a  number  of  the  moder- 
ately severe  cases  and  in  one  of  the  severe,  the  threshold  was 
below  0.15  per  cent.  Their  studies  were  made  on  patients  who 
had  become  sugar-free  after  treatment,  and  in  this  series  they 
did  not  find  any  with  a  high  threshold.  We  refer  in  our  next 
paragraph  to  the  case  of  Mr.  H.  who  had  a  threshold  of  0.216 
per  cent. 

It  is  interesting  to  note  in  connection  with  our  case  of  high 
threshold  that  Hammann  and  Hirschman,  in  concluding-  their 
contribution  on  this  subject  state  that  mild  cases  have  a  high 
threshold  and  many  severe  cases  a  lowered  threshold  and  that 
this  lowered  threshold  may  be  a  factor  in  the  severity:  certain 
it  is  our  case  reported  here  is  in  fairly  comfortable  condition 
even  though  not  under  scientific  control  because  of  his  propensity 
to  break  " training." 

From  our  own  experience,  there  seems  to  be  great  difficulty 
in  .estimating  what  the  normal  threshold  point  is,  and  it  is  for 


162 


BLOOD   AND    URINE    CHEMISTRY 


this  reason  that  blood  sugar  determinations  are  so  vital.  We 
have  data  which  show  higher  concentration  of  sugar  in  blood 
than  are  noted  by  the  above  investigators,  but  these  patients  did 
not  show  glycosuria.  For  instance,  a  very  interesting  case,  which 
was  studied  by  the  authors,  gave  us  a  figure  considerably  higher 
than  that  heretofore  considered  as  the  threshold  point  of  renal 
permeability  for  sugar.  It  will  be  noted  from  a  study  of  the 
figures  shown  in  the  accompanying  chart  of  the  case  of  Mr.  H., 
that  this  individual,  a  diabetic  for  years,  when  starved  for  several 
days,  easily  became  sugar-free  so  far  as  his  urine  was  concerned, 
but  his  blood  sugar  remained  high,  even  though  no  sugar  was 
present  in  the  urine  (Benedict's  test).  It  can  thus  be  seen  that  a 
rather  high  degree  of  hyperglycemia  may  exist  without  any  gly- 
cosuria. This  individual  believed  that  the  few  days'  starvation 
which  made  him  sugar-free  also  placed  him  in  a  state  of  normal 
carbohydrate  equilibrium.  The  result  of  these  blood  examina- 
tions, however,  convinced  him  of  the  error  of  his  judgment  in 
this  respect. 


CASE    OF    MR.    II. 


BLOOD 

URINE* 

Date 

Sugar  % 

CO: 

Combining 
Power  of 
Blood  Plasma 

Sugar 

Acetone 

Diacetic 
Acid 

7/10/1G 

0.330 

68 

7/14/16 

5%  or 
96  gms. 
in  24  hr. 
specimen 

Trace 

Trace 

7/25/16 

0.315 

85 

2.9%  or 
78  gms. 
in  24  hr. 
specimen 

Neg. 

Neg. 

8/16/16 

0.216 

Neg. 

+ 

+ 

8/19/16 

0.165 

53 

Neg. 

+  +  +  + 

+  +  +  + 

'+=SmaIl  amount; 


=Largc  amount. 


A  patient  may  be  truly  diabetic  and  may  have  kidneys  relatively 
impermeable  to  sugar  up  to  a  very  high  point.     Hence,  if  only 


BLOOD   SUGAR  163 

the  urine  were  examined  in  such  a  case,  the  negative  findings  would 
not  by  any  means  justify  us  in  eliminating  the  diagnosis  of  diabetes 
mellitus.  Again,  the  finding  of  abundance  of  sugar  in  the  urine 
alone  does  not  give  us  the  most  intelligent  idea  of  the  condition  of 
the  diabetic  and  the  amount  of  starvation  and  dietetic  treatment 
necessary  to  rid  him  of  his  glycosuria  and  his  hyperglycemia.  Rid- 
ding a  patient  with  diabetes  mellitus  of  glycosuria  does  not  by  any 
means  indicate  that  he  is  in  a  state  of  carbohydrate  tolerance. 
We  must,  if  possible,  reduce  his  blood  sugar  to  some  figure  around 
the  normal  of  0.08  to  0.12  per  cent.  If  we  can  make  him  "sugar- 
free"  so  far  as  the  urine  is  concerned,  together  with  low  blood 
sugar  content,  then  we  have  the  case  in  a  condition  where  we 
can  have  some  hope  of  the  performance  of  ideal  normal  meta- 
bolism. 

Again,  it  must  be  remembered  that  the  advantage  of  a  blood 
chemical  estimation  of  sugar  can  be  seen  from  a  survey  of  the 
opinions  of  the  authorities  as  to  what  constitutes  the  "normal" 
for  sugar  in  the  urine.  Folin4  states  that  he  could  demonstrate 
the  presence  of  sugar  in  human  urine  in  nearly  every  one  of  the 
hundred  persons  upon  whom  he  tried  out  this  procedure  and  adds, 
"The  amount  of  sugar  present  in  normal  human  urine  is  there- 
fore probably  much  greater  than  is  indicated  by  the  negative 
findings  recorded  on  the  basis  of  the  clinical  qualitative  tests  for 
sugar  in  common  use."  Benedict,5  in  a  personal  communication 
to  Joslin,  on  the  other  hand,  claims  that  his  qualitative  test  per- 
formed according  to  his  later  technic  will  detect  glucose  in  as 
low  a  concentration  as  0.01  to  0.02  per  cent,  provided  the  urine 
is  of  low  dilution.  Joslin6  says  that  these  views  hardly  coincide 
nor  do  they  coincide  with  the  views  of  the  older  investigators 
wrho  supposed  that  normal  human  urine  contained  as  much  as 
0.5  per  cent.  Joslin  further  states7  that,  "It  seems  quite  im- 
possible to  demarcate  sharply  between  normal  and  pathological 
urines  with  reference  to  the  sugar  output."  It  can  thus  easily 
be  seen  that  the  importance  of  blood  sugar  determinations  can- 
not be  overlooked.  Here  wre  have  a  doubtful  status  as  to  what 
constitutes  a  "normal"  amount  of  sugar  in  the  urine;  on  the 


4Folin:     Jour.   Biol.   Chem.,   1915,  vol.   xxii,   p.   327. 

BRenedict":      Joslin    (quoted),    Diabetes   Mellitus,   J.    15.    Lippincott    Company,    1916. 

"Joslin:     loc.  cit. 

'Joslin:   loc.  cit 


164  BLOOD    AND   URINE    CHEMISTRY 

other  hand  there  does  not  seem  to  be  any  doubt  as  to  what  is 
the  normal  for  blood  sugar;  it  lies  between  0.08  and  0.12  per 
cent;  anything  above  this  would  be  termed  hyperglycemia  and 
to  this  figure  we  would  have  to  turn  in  the  presence  of  a  "doubt- 
ful glycosuria. " 

One  of  the  many  points  of  interest  that  occurred  to  be  the  au- 
thors9 to  determine  in  connection  with  sugar  in  the  blood  as  de- 
terminable  by  the  present  methods  of  colorimetry  is  the  exact 
distribution  of  the  sugar  content  in  whole  blood,  in  cells 
and  in  plasma.  The  data  which  we  have  accumulated  are  based 
upon  a  number  of  analyses  of  blood  obtained  in  the  way  already 
described  in  the  chapter  on  blood  sugar  determinations.  Before 
this  research  no  data  had  ever  been  obtained  on  this  question 
by  the  use  of  the  modern  microchemical  methods. 

Possibly  the  most  important  research  along  this  line  is  that 
of  Tachau10  who  reported  his  data  on  the  distribution  of  blood 
sugar  in  blood  corpuscles  and  blood  serum.  Prior  to  this  publication, 
Lepine,11  Michaelis  and  Rona,12  and  Hollinger13  found  in  the  blood 
serum  and  corpuscles  of  man  and  other  animals  different  amounts 
of  blood  sugar.  Since  then,  others  have  worked  along  similar 
lines,  notably  Kona  and  Doblin,14  E.  Frank,13  Lyttkens  and  Sand- 
green,10  Hoeber,17  Schirokauer,18  and  others.  There  are  great 
discrepancies  in  these  results,  possibly  due  to  the  fact  that  some 
work  was  carried  out  with  human  blood  and  other  work  with 
animal  blood.  Since  the  appearance  of  Masing's19  and  Loeb's20 
articles,  we  know  that  the  sugar  content  of  blood  in  different 
animals  and  in  man  gives  different  figures,  and  also  that  the 
variations  in  the  blood  sugar  in  man  and  in  animals  quite  close  to 
him  are  different  from  a  metabolic  standpoint.  It  must,  however, 
be  noted  that  the  observations  of  most  of  these  investigators 
have  not  been  made  with  respect  to  an  estimation  of  the  normal 


"Gradwohl,    R.    B.    II. ,   and    Blaivas,   A.   J.:     Jour.    I,ab.   and    Clin.    Mod.,    March,    1917 
ii,  No.  6. 

10Tachau,   II.:     Ztschr.   f.  klin.   Med.,   1914,  vol.  Ixxix,  p.   421. 

"Lepine:     Le  diabete  sucre,  1909. 

"Michaelis  and   Kona:      Biochem.   Ztschr.,    1909,   vol.   xvi,   p.   60. 

"Hollinger:     Biochem.  Ztschr.,   1909,  vol.  xvii,  p.   1. 

"Rona  and  Doblin:     Biochem.  Ztschr.,   1911,  vol.  xxxi,  p.  215. 

1BFrank,   E.:     Ztschr.   f.  physiol.   Chem.,   1911,  vol.   Ixx,   p.   135. 

"Lyttkens  and  Sandgreen:     cited  by  Bang:     Der  Blutzuckcr,  1913. 

"Hoeber:      Biochem.   Ztschr.,    1912,   vol.   xlv,   p.    207. 

"Schirokauer:      Berl.   klin.   Wchnschr.,    1912,   No.   28. 

"Masing,    E. :      Pflueger   Arch.,    1912,   vol.    cxlix,   p.    227. 

a'Loeb:      Biochem.   Ztschr.,    1913,  vol.  xlix,  p.   413. 


BLOOD   SUGAR  165 

blood  sugar  content  under  ordinary  conditions,  most  of  the  human 
data  having  been  based  upon  a  computation  after  the  ingestion 
of  large  amounts  of  carbohydrates  and  most  of  the  animal  data 
having  been  procured  after  the  animals  were  narcotized  and  tied 
up  for  a  long  time.  Michaelis  and  Rona21  and  E.  Frank22  showed 
that  in  the  presence  of  a  hyperglycemia  due  to  the  ingestion  of 
a  large  amount  of  carbohydrates,  the  blood  sugar  content  of 
serum  is  increased  more  than  that  of  the  whole  blood  or  the 
corpuscles.  As  for  the  results  in  man,  Hollinger  found  that  the 
amount  of  sugar  was  the  same  in  whole  blood  and  in  plasma.  E. 
Frank,  in  a  number  of  pathologic  cases,  found  more  sugar  in 
the  serum.  Schirokauer,  as  a  rule,  in  fasting  persons,  found  a 
higher  percentage  of  blood  sugar  in  plasma  than  in  whole  blood 
or  corpuscles.  In  alimentary  hyperglycemia  the  difference  be- 
tween the  whole  blood  and  the  plasma  was  quite  marked  in  a 
number  of  cases  examined.  It  was  noted  that  one  hour  after 
the  ingestion  of  the  dose  of  carbohydrate  that  caused  the  alimen- 
tary hyperglycemia,  the  balance  between  the  two  was  adjusted  so 
that  there  was  practically  no  more  difference  between  the  blood 
sugar  content  in  carbohydrate-fed  persons  than  that  seen  in 
fasting  persons.  The  blood  sugar  in  the  corpuscles  of  alimentary 
hyperglycemics  ran  high;  in  but  few  cases  did  the  concentra- 
tion of  sugar  in  the  corpuscles  remain  low ;  and  in  one  case,  when 
the  blood  sugar  concentration  in  the  whole  blood  went  up,  the 
blood  sugar  in  the  corpuscles  went  down. 

As  for  the  different  results  seen  in  the  case  of  man,  Hollinger 
found  the  same  amounts  of  sugar  in  plasma  and  in  whole  blood. 
E.  Frank,  in  pathological  cases,  found  an  increase  in  the  sugar 
in  the  serum  over  the  corpuscles,  while  Schirokauer  found  great 
differences  between  the  whole  blood  and  the  serum.  Tachau 
worked  this  matter  out  on  fasting  persons.  At  the  same  time, 
Roily  and  Oppermaim23  published  their  figures  on  fasting  per- 
sons. Tachau  reported  both  pathological  cases  and  als6  normal 
people  after  carbohydrate  ingestion.  Owing  to  the  fact  that  very 
large  quantities  of  blood  were  needed  with  this  technic  Tachau 
could  not  use  the  same  person's  blood  more  than  once.  His 


21Michaelis   and    Uona:      Loc.    cit. 

-Frank,  E.:     Loc.  cit. 

;3Rolly   and   Oppermann:      Biochem.    Ztschr.,    1913,   vol. 


166 


BLOOD    AND    URINE    CHEMISTRY 


teclmic  was  as  follows :  Blood  obtained  by  venipuncture  was 
received  in  sodium  fluoride,  40  c.c.  in  quantity,  centrifuged  in  a 
high  power  electric  centrifuge  for  fifteen  minutes.  The  blood 
volume  was  taken  with  a  Boenning  tube.  The  whole  blood  and 
corpuscles  were  treated  according  to  Schenk's  method  to  pre- 
cipitate the  protein  material,  and  blood  sugar  estimation  made 
Avith  the  Knapp  solution  as  previously  reported  by  Tachau.24 
A  point  to  be  taken  into  consideration  in  this  work  is  the  sug- 
gestion made  by  Lepine25  that  there  is  "free"  and  "bound" 
sugar  in  the  blood ;  i.  e.,  that  shortly  after  standing,  within  fifteen 
minutes,  in  fact,  some  of  the  "bound"  sugar  is  liberated  and  be- 
comes "free"  sugar,  going  over  from  corpuscles  to  plasma,  re- 
maining of  course  in  the  plasma.  Tachau  covered  this  question 
in  his  investigations.  A  part  of  the  blood  was  placed  directly 
in  water  and  2  per  cent  hydrochloric  acid  as  described  in  his 
previous  technic;  another  part  was  received  into  the  sodium 
fluoride  and  allowed  to  stand  one  hour  in  the  laboratory.  The 
blood  volume  was  determined  by  weighing.  Table  XII  of 
Tachau 's  experiments  give  the  results  on  this  question. 


TABLE  XII 


CASE 

NO. 

PER   CENT 

PER   CENT 
AFTER  1   HR. 

1. 

Potator 

(after 

100  gm. 

grape 

sugar) 

0.113 

0.111 

9 

Liver   cirrhosis 

" 

it       it 

1  1 

" 

0.142 

0.145 

3. 

it            ti 

« 

n       it 

" 

" 

0.143 

0.142 

0.148 

0.148 

4. 

Erysipelas 

•'< 

"       " 

11 

" 

0.185 

0.183 

5. 

Diabetes    (fasting  patient) 

0.258 

0.240 

6. 

Liver  cirrhosis, 

(after 

100   gm. 

grape 

sugar1) 

0.169 

0.177 

7. 

Gout 

'  ' 

1  1       it 

'  ' 

0.108 

0.112 

0.114 

8. 

Normal, 

ti 

it       it 

" 

'  ' 

0.08(5 

0  005 

o. 

Diabetic,  fasting 

" 

" 

0.113 

0.125 

It  will  be  noted  that  in  the  first  four  cases,  the  difference  be- 
tween the  blood  sugar  content  when  first  withdrawn  and  after 
one  hour  standing  is  so  slight  as  to  be  negligible.  In  case  5,  a 
fasting  diabetic,  blood  sugar  dropped  from  0.258  to  0.240  per- 
cent ;  here  perhaps  the  sodium  fluoride  caused  glycolysis.  In 
the  last  four  cases,  the  blood  sugar  rose  after  one  hour.  It  can 


=4Tachau:     Deiilsch.   Arch.   f.   klin.   Mod.,    1911,   vol. 
-'F.cpine:      Le  dialit-te  sticrc,   1909. 


BLOOD   SUGAR 


167 


be  seen  therefore  that  there  is  some  slight  rise,  but  this  is  not  a 
constant  or  important  factor. 

In  Table  XIII  of  Tachau's  figures  are  seen  the  results  of  in- 
vestigations on  fasting  people. 

TABLE  XIII 

INVESTIGATIONS  ON  FASTING  PERSONS 


SUGAR  CONTENT 

Case 

No. 

Diagnosis 

Whole 

Plasma 

Differ- 
ence 
Between 
Plasma 

Quotient 
Plasma 

Blood 

Cor- 

Differ- 
ence 
Between 
Plasma 

Quo- 
tient 
Plasma 

Blood 

% 

% 

and 
Whole 

Whole 

Volume 

puscles 
% 

and 
Cor- 

Cor- 

Blood 

% 

Blood 

puscles 

puscles 

1 

Pregnancy  .... 

/0.0765\ 
\  0.0740J 

0.087 

0.012 

1.16 

36 

fO.058 
10.051 

0.029 
0.036 

1.5 

1.7 

2 

Arteriosclerosis 

0.098 

0.105 

0.007 

0.07 

30 

0.082 

0.023 

1.3 

3 

Uremia  

JO.  105 
\0.104 

0.110 

0.005 

.05 

34 

0.095 

0.015 

1.2 

4 

Nephritis  

.111 

0.126 

0.015 

.14 

45 

0.093 

0.033 

1.4 

5 

Diabetes  

.129 

0.138 

0.009 

.07 

50 

0.120 

0.018 

1.2 

6 

" 

.150 

0.173 

0.023 

.15 

47 

0.125 

0.048 

1.4 

7 

« 

f    .1531 
\    .156J 

0.168 

0.014 

.09 

.... 

8 

.165 

0.165 

0 

.00 

27 

0.165 

0 

1.0 

9 

M 

.183 

0.185 

0.002 

.01 

42 

0.181 

0.004 

1.0 

10 

.243 

0.246 

0.003 

.01 

11 

M 

.258 

0.265 

0.007 

.03 

/0.301\ 

JO.  022 

1.07\ 

[O'.2i9 

o!io4 

i!5' 

12 

(0.306/ 

0.323 

10.017 

1.06J 

21 

10.243 

0.080 

1.3 

With  the  exception  of  case  8,  in  which  all  the  figures  tallied, 
the  sugar  concentration  was  higher  in  plasma  than  in  whole  blood. 
The  average  difference  was  0.01  per  cent.  The  average  quotient 
was  1.07.  As  for  the  volume,  the  difference  between  the  plasma 
and  the  whole  blood  was  greater  in  ratio  to  the  blood  volume; 
i.  e.,  the  greater  the  difference,  the  smaller  the  blood  volume. 
The  greatest  difference  between  the  plasma  and  the  corpuscles 
was  0.104  per  cent,  an  average  of  0.030  per  cent.  The  quotient 
average  of  plasma  over  corpuscles  is  1.3.  There  seemed,  there- 
fore, no  more  difference  between  the  blood  sugar  concentration 
in  whole  blood,  plasma,  and  corpuscles  in  individuals  wilh  a  high 
or  low  blood  sugar. 

Table  XIV  by  Tachau  illustrates  the  data  on  blood  after  the 
administration  of  carbohydrates. 

The  differences  between  the  sugar  in  the  plasma  and  in  the 
whole  blood  or  corpuscles  are  greater  the  higher  the  hypergly- 


168 


BLOOD    AND    URINE    CHEMISTRY 


TABLE  XIV 

EXAMINATIONS  AFTER  INSTITUTION  OF  CARBOHYDRATES 


SUGAR  CONTENT 

Differ- 
ence 
Be- 

Quo- 

Differ- 
ence 
Be- 

Quo- 

Case 
No. 

Diagnosis 

Remarks 

Whole 

Plas- 

tween 
Whole 

tient 
Plas- 

Blood 
Vol- 

Cor- 

tween 
Plas- 

tient 
Plas- 

Blood 

ma 

Blood 

ma 

ume 

puscles 

ma 

ma 

and 
Plas- 
ma 

Whole 
Blood 

70 

and 
Cor- 
puscles 

Cor- 
puscles 

1  hr.  after 

1 

Healthy  

100  Gm.  Grape 

0.090 

0.112 

0.022 

1.25 

.Sugar 

2 

Heart  Insuffi- 

0.093 
0.096 

0.018 
0.120 

0.022 
0.027 

1.29 
1.23 

40 
40 

0.053 
0.063 

0.055 
0.063 

2.3 

1.8 

ciency  

0.112 

i 

3 

Gout  

"         

JO.  129 

0.016 

1.15 

4 

Nephritis  

« 

o!l42 

0.155 

0.013 

1.09 

45 

0.127 

0.028 

1.2 

5 

Liver  Cirrhosis 

/0.143 
10.148 

0.153 
0..155 

0.005 
0.002 

1.031 

1.08J 

6 

Uremia  

" 

0.147 

0.160 

0.013 

1.09 

7 

Liver  Cirrhosis 

0.169 

0.213 

0.044 

1.26 

"39" 

'6!ioo 

0  113 

2   1 

8 

Erysipelas.  .  .  . 

« 

0.182 
,0.185 

J0.207 

0.024 

1.13 

9 

Lead  Poisoning 

0.213 

0.237 

0.024 

1.11 

47 

0.185 

0.052 

1.3 

fl  hr.  after 

1 

10 

Diabetes  

J  50  Gm.  White 

k).221 

0.231 

0.010 

1.05 

50 

0.212 

0.019 

1.1 

.Bread  

J 

11 

" 

" 

0  334 

0.480 

0.146 

1.44 

12 

« 

" 

0.361 

0.387 

0.026 

1.07 

41  5 

'6!325 

0  062 

'i'.z" 

[\1A  hrs.  after 

13 

Healthy  

100  Gm.  Grape 
Sugar  

0.093 

0.075 

0.018 

0.80 

47 

IK  hr.  after 

1 

14 

Drinker  

100  Gm.  Grape 

0.111 

^0.126 

0.014 

1.13 

Sugar  
[2  hrs.  after 

0.113 

j 

15 

Arteriosclerosis 

UOO  Gm.Grape 
[Sugar     

0.056 

0.058 

0.002 

1.03 

46 

0.054 

0.004 

1.07 

16 

« 

0.092 

0.086 

0.006 

0.94 

40 

0.100 

0.014 

0.86 

17 

Carcinoma 

Liver  

« 

0.111 

0.129 

0.018 

1.16 

37 

0.081 

0.048 

1.6 

18 

Liver  Cirrhosis 

« 

10.142 
\0.145 

0.188 
0.193 

0.043 
0.051 

1.30 
1.36 

}36< 

0.051 
0.070 

0.142 
0.118 

3.8 

2.7 

19 

Diabetes  

u 

0.180 

0.225 

0.045 

1.25 

37 

0.103 

0.122 

2.2 

20 

Acromegalia  .  . 

« 

0.206 

0.240 

0.034 

1.17 

30 

0.127 

0.113 

1.9 

21 

Diabetes  

« 

0.295 

0.312 

0.017 

1.05 

47 

0.277 

0.035 

1.1 

<2H  hrs.  after' 

22 

"        

50  Gm.  White 
Ifiread  

0.126 

0.126 

0 

1.00 

31 

0.126 

0 

1.0 

[2J4  hrs.  after 

23 

• 

\l  00  Gm.  White 

0.325 

0.344 

0.019 

1.06 

41.5 

0.300 

0.044 

1.1 

Bread  

f3   hrs.   after 

24 

• 

150Gm.  White 

0.428 

0.386 

0.012 

0.90 

45 

0.480 

0.094 

0.8 

Bread  

4     hrs.     after 

25 

« 

50  Gm.  White 

0.234 

0.228 

0.006 

1.00 

42 

0.243 

0.015 

0.9 

Bread  

cemia,  as  opposed  to  the  condition  existing  in  fasting  persons. 
The  greatest  difference  occurred  in  case  11,  0.144  per  cent,  in  a 
diabetic,  the  quotient  of  whole  blood  over  plasma  being  1.4. 
The  quotient  of  plasma  over  corpuscles  was  in  most  cases  as  much 


BLOOD   SUGAR  169 

as  2.0.  In  twelve  of  these  eases  where  the  patients  were  given 
carbohydrates  followed  by  a  blood  test,  the  quotient  of  plasma 
over  whole  blood  was  five  times  higher  than  in  fasting  persons 
(Table  XIII).  In  the  cases  where  the  examinations  were  made 
one  hour  after  carbohydrates  were  ingested,  the  whole  blood 
was  higher  in  sugar  than  was  the  plasma.  'In  cases  13  and  24 
the  differences  were-  so  great  that  they  could  not  possibly  be 
due  to  errors  in  technic  or  calculation.  In  one  case  the  sugar 
concentration  in  whole  blood  went  up  and  that  of  the  corpuscles 
diminished,  due  to  the  fact  that  the  corpuscles  must  have  yielded 
up  some  of  their  sugar.  This  phenomenon  was  first  noted  by 
Rona  and  Takahashi26  and  E.  Frank  and  Bretschneider.27  Tachau 
also  claims  that  the  increase  in  sugar  concentration  in  the  cor- 
puscles, observed  in  alimentary  hyperglycemia,  was  due  to  the 
relative  permeability-increase  in  vitro  in  human  corpuscles  for 
grape  sugar,  as  suggested  by  Rona  and  Doblin,  Hoeber  and 
basing.19  We  can  think  of  it  in  this  way :  when  the  alimentary 
hyperglycemia  begins  and  sugar  is  thrown  in  increased  quantity 
into  the  circulation,  it  is  first  dissolved  in  plasma  and  penetrates 
the  .corpuscles  secondarily.  As  the  hyperglycemia  declines,  the 
sugar  content  of  the  plasma  goes  down  and  the  corpuscles  then 
throw  their  sugar  in  excess  into  the  plasma.  Tachau  attempts 
to  explain  by  this  line  of  reasoning  why  it  is  that  in  the  presence 
of  a  declining  hyperglycemia  of  alimentary  origin,  the  serum 
loses  its  sugar,  and  strange  to  say,  the  corpuscles  then  hold  more 
sugar  than  the  plasma.  Perhaps  this  is  due  to  a  sudden  libera- 
tion of  sugar  from  the  blood  stream.  In  this  connection  the  work 
of  E.  biasing28  bears  strongly  on  this  point:  he  showed  by  ex- 
haustive experiments  that  the  addition  of  sugar  to  a  quantity  of 
blood  in  vitro  is  followed  by  the  taking  up  of  the  sugar  by  the  cor- 
puscles first;  then  later  the  corpuscles  give  up  this  sugar  excess 
and  in  the  final  analysis  sugar  in  larger  quantities  is  found  in 
the  plasma.  This  is  in  confirmation  of  the  work  of  Rona29  and 
the  prior  publication  of  Masing.30  Masing  further  showed  that 
the  addition  of  sugar  to  blood  was  followed  by  the  slow  entrance 


=*Rona  and  Takahashi:     Biochem.  Ztschr.,   1911,  vol.  xxx,  p.  99. 

^Frank,    E-,    and    Bretschneider:      Ztschr.    f.    physiol.    Chem.,    1911,   vol.    cxxi,    p.    157. 

^Masing,    E.:      Pflueger  Arch.   f.   Physiol.,   1914,  vol.   clvi,   clvii.   No.   8,   401. 

'"Rona:     Biochem.  Ztschr.,  vol.  xxxi,  p.  215. 

"Masing,  E.:     Pflueger  Arch.  f.   Physiol.,  vol.   cxlix,  p.  227. 


170 


BLOOD   AND   URINE    CHEMISTRY 


of  sugar  into  the  corpuscles  at  zero  Centigrade,  faster  at  25°  C., 
and  that  this  entrance  was  hindered  markedly  by  high  temper- 
atures. Masing  also  showed  that  treatment  of  corpuscles  with 
formalin  enhanced  their  permeability  for  sugar. 

Table  XV  of  Tachau's  data  on  the  same  persons  and  on  ex- 
perimental animals,  eight  cases  in  all,  showed  a  great  difference 
between  the  sugar  content  of  plasma  and  corpuscles  in  case  4, 

TABLE  XV 

INVESTIGATIONS  ON  THE  SAME  PERSONS  AND  EXPERIMENTAL  ANIMALS 


SUGAR  CONTENT 

Differ- 
ence 

Quo- 

Case 
No. 

Diagnosis 

Remarks 

Blood 

Whole 

Plasma 

Cor- 

Plasma 

tient 
Plasma 

Vol- 

Blood 

and 

ume 

% 

Cor- 

Cor- 

% 

puscles 

puscles 

1 

Nephritis  

[Fasting    1    hr.    after 
100    Gm.    Grape 
Sugar  

V     45 

'0.111 
\0.142 

0.126 
0.155 

0.093 
0.125 

0.0331 

0.033/ 

1.8 

2 

Diabetes  

(Fasting    1    hour. 
{  After      50      Gm. 
1  White  Bread  

50 

JO.  129 

\0.221 

0.138 
0.231 

0.120 
0.212 

0.018 
0.019 

1.2 
1.1 

j  0.243 

0.2461 

3 

10.334 

0.480/ 

4 

« 

(Fasting      2      hours. 
After       100       Gm. 
Grape   Sugar  

47 

JO.  150 
10.295 

0.173 
0.312 

0.125 
0.277 

0.048 
0.035 

1.4 
1.1 

5 

•• 

fFasting       1       hour. 
•i  After        100        Gm. 
i  White  Bread  

41.5 

fO.361 
\0.325 

0.387 
0.344 

0.325 
0.300 

0.062 
0.044 

1.2 
1.1 

6 

Dog  1,  Police 
Dog  

(Fasting      ?-.(      hour. 
After       100       Gm. 
Grape  Sugar  

43 

/0.081 
|0.213 

0.090 
0.264 

0.070 
0.146 

0.020 
0.118 

1.3 

1.8 

7 

Dog  2,  Bull  Dog... 

Fasting       1       hour. 
After      80       Gm. 
Grape  Sugar  

36 

JO  081 
\0.150 

0.087 
0.159 

0  069 
0.133 

0.018 
0.026 

1.3 
1.2 

8 

" 

Fasting     1  '.i     hours 
After       120        Gm. 
Grape  Sugar  

36 

/  0  .  082 
\0.223 

0.087 
0.174 

0.072 
0.311 

0.010 
0.137 

1.1 
0.6 

a  diabetic,  blood  taken  two  hours  after  100  grams  of  grape  sugar 
were  administered.  The  difference  was  0.048  per  cent.  The 
greatest  difference  was  in  case  5,  0.062  per  cent,  a  diabetic,  fast- 
ing one  hour  after  100  grams  of  white  bread  were  ingested.  It 
is  significant  to  note  that  the  three  dogs  examined,  cases  6,  7,  and 
8,  showed  about  the  same  percentage  of  blood  sugar  in  their 
whole  blood :  viz.,  0.081,  0.081,  and  0.082  per  cent,  respectively.  The 
least  difference  found  between  plasma  and  corpuscles  was  in  case 
8,  0.010  per  cent,  and  the  greatest  in  case  5,  0.062  per  cent. 


BLOOD    SUGAR 


171 


Our  figures  are  based  upon  a  comparison  of  the  blood  sugar 
content  of  24  cases,  using  the  latest  method,  that  of  Benedict  and 
Lewis31  modified  by  Myers  and  Bailey.32  The  blood  was  diluted 
one  to  five  with  distilled  water,  immediately  after  withdrawal, 
precipitated  with  picric  acid,  mixed  with  a  stirring  rod,  and 
allowed  to  stand  with  occasional  stirring.  The  tube  is  now  cen- 
trifuged  for  a  few  minutes  and  the  supernatant  fluid  filtered 


TABLE  XVI 

ANALYSIS  OF  WHOLE  BLOOD,  PLASMA  AND  CELLS 


No. 

Name 

Sex* 

Date 

Whole 
Blood 

Plas- 
ma 

Cells 

REMARKS 

1 

W.M.... 

A 

8/8 

0.135 

0.135 

0.135 

Patient  normal.     Blood   taken   after  break- 

fast.  • 

2 

F.B  

A 

8/15 

0.132 

0.129 

0.132 

Patient  normal.     Blood   taken   after   break- 

fast. 

3 

Dr.H.... 

A 

8/16 

0.204 

0.204 

0.200 

Patient  diabetic. 

4 

M.H  

A 

8/18 

0.156 

0.153 

0.156 

Patient  epileptic. 

5 

Dr.H.... 

A 

8/19 

0.165 

0.162 

0.165 

Patient  fasting  six  days. 

6 

C.B  

A 

8/22 

0.159 

0.155 

.159 

Patient  syphilitic.      Blood  taken  after  dinner. 

7 

F.H  

A 

8/22 

0.140 

0.138 

.140 

Patient  syphilitic.    Blood  taken  before  break- 
fast 

8 

E.B  

A 

8/23 

0.300 

0.225 

.240 

Case  of  boy  of  12  years  who  was  dying  at  the 
time  blood  was  taken  (Diabetic  Coma). 

9 

B.E.S.... 

A 

8/31 

0.132 

0.129 

.132 

Blood  taken  after  injection  of  salvarsan. 

10 

J.W  

9/13 

0.200 

0.196 

.196 

Patient  diabetic. 

11 

Dr.H.... 

A 

9/16 

0  225 

0.225 

.225 

See  cases  No.  3  and  5. 

12 

9697  .  . 

A 

9/18 

0.135 

0.135 

.132 

Patient  syphilitic.     Wassermann  +  +  +  +  - 

13 

14 

G.M  
M.R  

A 

9/18 
9/20 

0.123 
0  345 

0.123 
0.340 

.123 
.340 

Patient  syphilitic. 
Patient  diabetic. 

15 

E.G  

A 

9/21 

0.144 

0.144 

.144 

16 

J.R  

10/3 

0.120 

0.120 

.120 

Patient  on  "Allen  Treatment"  since  9/27. 

17 

J.R  

— 

10/19 

0.129 

0.129 

.129 

See  case  No.  16. 

18 
19 

M.M.... 
F.S  

A 

10/20 
11/10 

0.090 
0.102 

0.090 
0.099 

.090 
.102 

Patient  pregnant  and  has  only  one  kidney. 
Patient  normal.    Blood  taken  after  breakfast. 

20 

M.S  

11/20 

0.138 

0.138 

.138 

Patient  on  "Allen  Treatment"  since  11/17. 

21 

G.D  

= 

11/21 

0.102 

0.102 

0.099 

Patient  syphilitic  and  has  a  trace  of  sugar  in 

urine. 

22 

P.R  

A 

11/21 

0.087 

0.084 

0.087 

Blood    taken    one    hour    after    injection    of 

salvarsan. 

23 

M.G  

A 

11/25 

0.210 

0.207 

0.210 

Patient  syphilitic. 

24 

B.P  

A 

11/25 

0.120 

0.120 

0.117 

Patient  diabetic. 

*   ASignifies  Male. 
= Signifies  Female. 

into  a  dry  test  tube  through  a  small  thick  piece  of  filter  paper. 
Three  c.c.  of  the  filtrate  are  pipetted  into  a  specially  graduated 
test  tube,  1  c.c.  of  20  per  cent  sodium  carbonate  added,  and 
the  solution  heated  for  fifteen  minutes  for  the  development  of 
color.  The  solution  is  allowed  to  cool,  made  to  volume  with  water, 
10,  15,  or  20  c.c.,  dependent  upon  depth  of  color,  mixed  and  com- 
pared in  the  Hellige  colorimeter  with  the  wedge  of  standard 

"Benedict  and  Lewis:     Jour.  Biol.   Chem.,   1915,  vol.  xx,  p.  61. 


172  BLOOD   AND    URINE    CHEMISTRY 

picramic  acid.  In  these  determinations,  of  course,  we  worked 
with  another  part  of  the  same  blood,  which  was  strongly  cen- 
trifuged  beforehand,  in  that  way  separately  gathering  the  plasma 
and  the  cells.  The  plasma  and  the  cells  in  turn  were  handled 
in  the  same  way  as  was  the  whole  blood. 

Table  XVI  shows  the  results  of  our  own  investigations. 

From  a  study  of  these  twenty-four  examinations  it  can  be  readily 
seen  that  the  quantity  of  sugar  in  the  whole  blood,  in  the  plasma, 
and  in  the  corpuscles  in  nearly  all  cases  is  the  same.  Our  cases 
were  normal  individuals,  syphilitics,  diabetics  before  and  after 
undergoing  "Allen"  treatment,  and  one  epileptic.  Our  figures 
agree  rather  closely  with  those  of  Tachau  already  cited  at  length. 
In  but  one  case,  No.  8,  did  we  see  a  wide  variation  from  this 
agreement :  here  we  had  0.30  per  cent  in  the  whole  blood,  0.225 
per  cent  in  the  plasma  and  0.24  per  cent  in  the  cells.  This  was 
a  very  interesting  case  of  a  boy  of  twelve  years  who  died  within 
twenty-four  hours  after  admission  into  the  City  Hospital  of 
Avhat  was  judged  to  be  diabetic  coma.  The  thought  suggested 
itself  that  in  the  terminal  stages  of  life,  in  diabetes,  there  is 
perhaps  a  variation  in  the  sugar  content  of  the  various  parts 
of  the  blood,  but  as  yet  we  have  had  no  opportunity  in  diabetic 
coma  cases  to  verify  this  observation. 

Conclusion. — Using  the  latest  methods  of  sugar  analysis  in 
blood,  namely,  that  of  Lewis  and  Benedict  as  modified  by  Myers 
and  Bailey,:i2  we  find  that  the  amount  of  sugar  is  practically  the 
same  in  the  whole  blood,  plasma,  and  cells.  This  is  in  the  main 
in  perfect  agreement  with  the  work  of  Tachau  who  used  the 
older  technic  of  sugar  estimation.  This  seems  to  disprove  the 
theoretical  views  of  some  of  the  older  physiologists  who  held 
that  a  part  of  the  sugar  in  the  blood  was  in  a  state  of  loose  com- 
bination with  some  other  substance.  This  obsolete  idea  has,  of 
course,  already  been  considerably  shaken  by  the  work  of  Rona 
and  Michaelis33  who  showed  that  blood  sugar  is  in  a  state  of 
solution;  they  showed  that  when  diluted  blood  is  shaken  with 
certain  colloids,  such  as  ferric  chloride  or  kaolin,  the  proteins 
form  a  colloidal  combination,  and  are  absorbed.  They  can  then 
be  quantitatively  precipitated  by  the  addition  of  a  trace  of  elec- 


32Myers  and   Railey:     Jour.   Riol.   Chem.,   1916,   vol.   xxiv,   No.   2,  p.    1-47. 
MRona  and    Michadis:      I'.iochcm.   Ztschr.,    1909,   vol.   xiv. 


BLOOD   SUGAR  173 

trolyte,  but  no  trace  of  sugar  is  removed  from  the  solution  by 
this  treatment.  If  the  sugar  were  united  with  the  proteins  it 
would  be  carried  down  with  them,  and  as  the  reagents  used  can 
not  have  any  disruptive  effect,  it  is  not  possible  for  the  sugar 
to  exist  in  combination  with  the  proteins.  As  Cammidge34  states, 
too,  another  piece  of  evidence  in  support  of  the  free  state  of  dex- 
trose in  the  blood  is  furnished  by  the  observation  that,  whereas 
charcoal  absorbs  both  sugar  and  protein  when  shaken  with  a 
solution  containing  these  two  substances,  yet  it  absorbs  the  pro- 
tein, but  not  the  dextrose,  when  acetone  is  present.  The  acetone 
being  more  absorbable  than  the  dextrose,  prevents  the  latter 
being  taken  up  by  the  charcoal.  Further  evidence  is  also  fur- 
nished by  the  results  of  dialysis  experiments. 

It  is  interesting  to  note  the  experimental  work  on  the  tolerance 
for  glucose  in  normal  and  diabetic  subjects.  Cummings  and 
Piness35  covered  the  question  very  well  and  their  figures  may 
well  be  herein  considered.  They  noted  the  wide  variations  met 
with  in  the  literature  as  to  what  various  writers  consider  the 
"normal"  percentage  of  blood  sugar.  Naunyn  and  Abeles36  give 
it  as  0.07  to  0.10  per  cent;  Klemperer,37  0.06  to  0.11;  Hollinger 
and  Knapp,38  0.07  to  0.10;  Bang  with  Bang's  micro-method,39  0.05 
to  0.11;  Frank  with  Bertrand's  method,40  0.06  to  0.11;  Purjez 
with  Bertrand's  method,41  0.045  to  0.087;  Kowarsky  with  Kowar- 
sky's  method,42  0.05  to  0.11;  Strause  with  Kowarsky 's  method,43 
0.04  to  0.088;  Hopkins  with  Bang's  method44  0.065  to  0.10.  Cum-, 
mings  and  Piness  tabulated  the  results  of  examinations  for  blood 
sugar  on  one  hundred  convalescent  male  patients,  with  normal 
digestive  systems,  who  were  about  to  be  discharged  from  the 
hospital.  The  specimens  wrere  all  taken  before  breakfast,  or  at 
least  three  hours  after  meals,  Hopkins  having  shown  that  the 
blood  sugar  had  fallen  to  the  same  level  three  hours  after  meals 
as  the  level  in  a  fasting  or  empty  stomach.  Their  figures  varied 

'"Cammidge,  P.  J.:  Glycosuria  and  Allied  Conditions,  Longmans,  Greene  &  Co.,  1913, 
p.  19. 

35Cummings   and   Piness:      Arch.    Int.    Med.,    1917,   vol.   v,   p.    777. 

MVaunyn:     Der  Diabetes  Mellitus,   1906. 

3TKlemperer:     Quoted  by  Bang,   Der  Blutzucker,   1913,  J.  F.   Bergman,   Wiesbaden. 

3sHollinger:      Deutsch.      Arch.    f.    klin.    Med.,    1909,   vol.    xcii,   p.    217. 

39Bang:     Der  Blutzucker,  1913,  J.  F.  Bergman,  Wiesbaden. 

40Frank:      Ztsch.   f.   physiol.    Chem.,    1910,   vol.   Ixx,   p.    129. 

"Purjez:      Wien.    klin.    Wchnschr.,    1913,   vol.    xxvi,    p.    1420. 

4:Kowarsky:      Deutsch.    Med.    Wchnschr.,    1913,   vol.   xxxix,   p.    1635. 

"Strause:      Bull.   Johns   Hopkins   Hosp.,    1915,  vol.   xxvi,   p.   292. 

"Hopkins:     Am.  Jour.  Med.  Sc.,   1915,  cxlix,  p.  254. 


.174  BLOOD   AND   URINE    CHEMISTRY 

from  0.044  to  0.120  per  cent  or  from  44  to  120  mg.  of  sugar  to 
100  c.c.  of  blood,  the  two  main  factors  producing  the  wide  dif- 
ferences being  errors  in  technic  and  disobedience  of  orders  about 
food  and  drink.  Their  maximum,  minimum  and  average  com- 
pare very  closely  to  those  of  the  writers  just  quoted.  They  then 
undertook  an  investigation  of  the  tolerance  of  normals  and  dia- 
betics for  glucose. 

They  then  estimated  in  fifty-eight  normal  subjects  the  tolerance 
of  sugar,  finding  the  maximum  amount  of  sugar  in  the  blood 
occurred  at  the  end  of  the  first  hour  following  the  ingestion  of 
100  gm.  of  glucose,  with  a  drop  almost  to  normal  at  the  end 
of  the  second  hour.  They  estimated  the  tolerance  for  sugar 
in  fourteen  cases  of  outspoken  diabetes,  finding  more  sugar  in 
the  blood  at  the  end  of  two  hours  after  the  ingestion  of  100  gms. 
of  glucose  than  at  the  end  of  one  hour,  as  in  normals.  They 
estimated  the  tolerance  for  sugar  in  two  subjects  who  had  ap- 
parently had  diabetes,  finding  a  marked  rise  during  the  first 
hour,  with  but  a  moderate  fall  during  the  second  hour.  They 
concluded  from  these  investigations  that  in  a  real  or  moderately 
severe  case  of  diabetes  the  blood  sugar  is  higher  two  hours  after 
giving  glucose  that  it  is  the  hour  after.  In  the  milder  forms 
of  diabetes  the  blood  sugar  is  normal,  but  following  the  ad- 
ministration of  100  gm.  of  glucose  the  rise  in  blood  sugar  will 
be  greater  than  normal,  and  especially  will  this  rise  be  sustained 
well  into  the  second  hour.  In  subjects  with  a  low  tolerance  for 
sugars,  the  rise  following  the  ingestion  of  100  gm.  of  glucose 
will  not  be  so  high  as  in  diabetes,  yet  it  is  distinctly  higher  than 
normal,  and  the  height  is  well  sustained  during  the  second  hour. 
These  results  seem  to  indicate  that  we  have  in  the  administra- 
tion of  glucose  to  suspected  diabetes  a  method  of  proving  out 
our  diagnosis.  Hammann  and  Hirschman45  further  call  attention 
to  this  test.  Their  method  was  to  give  a  single  and  constant  dose 
of  glucose  and  from  a  study  of  the  patient's  reaction  satisfac- 
torily determine  the  sugar  tolerance.  Their  method  of  testing 
is  as  follows :  Give  100  gm.  of  glucose  in  a  lemonade  in  the  morn- 
ing after  a  night  fast.  They  prepared  the  lemonade  by  dissolv- 
ing the  glucose  in  warm  water,  adding  the  juice  of  several  lemons, 


•''Hammann   and   ITirschman:     Loc.   cit. 


BLOOD   SUGAR  175 

or  of  two  lemons  and  an  orange,  making  the  mixture  up  to  300 
c.c.  and  cooling  by  packing  in  ice,  or  by  adding  ice  before  serv- 
ing. Such  a  mixture  is  not  disagreeable  to  take  and  rarely  causes 
nausea.  If  larger  quantities  of  water  are  taken,  patients  com- 
plain of  the  bulk  and  sometimes  of  nausea  after  drinking  it. 
The  blood  sugar  is  determined  before  the  glucose  is  given,  and 
thereafter  at  frequent  intervals.  Specimens  of  urine  are  col- 
lected immediately  before  or  immediately  after  each  blood  speci- 
men is  taken ;  or,  if  the  patient  is  unable  to  void  so  frequently, 
as  often  as  they  can  be  obtained.  The  urine  is  examined  care- 
fully for  sugar,  and  if  sufficient  be  present  the  quantity  is  de- 
termined separately  in  each  specimen.  These  frequent  veni- 
punctures  are  not  as  difficult  as  one  might  think  as  the  needle 
may  be  entered  into  the  same  puncture  point  each  time.  They 
believe,  however,  that  four  determinations,  one  before  adminis- 
tration of  the  glucose,  and  the  others  a  half  hour,  one  hour,  and 
two  hours  after,  will  give  all  needed  information.  They  found 
that  in  normal  persons,  after  the  ingestion  of  100  gms.  of  glucose 
the  blood  sugar  rises  promptly  to  a  level  not  exceeding  0.15  per 
cent;  the  high  point  is  usually  reached  within  thirty  minutes; 
from  the  high  point  the  blood  sugar  may  fall  off  as  quickly  as 
it  arose,  but  as  a  rule  it  is  gradual,  the  whole  reaction  lasting  one 
to  two  hours.  A  certain  number  of  normal  persons  have  a  low 
renal  threshold  point  for  glucose  so  that  sugar  appears  in  the 
urine,  although  the  blood  sugar  remains  below  0.14  per  cent.  The 
severity^of  diabetes  may  in  a  measure  be  estimated  by  this  in- 
gestion of  glucose,  judging  from  the  ease  with  which  the  patient 
may  be  rendered  free  of  sugar  by  fasting  and  his  ability  to 
utilize  carbohydrate  without  the  appearance  of  glycosuria.  These 
cases  by  means  of  this  test  may  thus  be  roughly  divided  into 
mild,  moderately  severe  and  severe  diabetes.  The  duration  of  the  re- 
action is  a  more  important  index  of  the  severity  of  thp  altera- 
tion of  carbohydrate  metabolism  than  the  height  of  the  reaction. 
A  definite  diuresis  accompanying  the  glycosuria  in  diabetics 
is  noticeable  in  severe  cases.  This  alimentary  test  for  disturbance 
in  glucose  utilization  is  essentially  the  same  in  diabetes  and  in 
other  conditions  with  low  sugar  tolerance,  notably  nephritis  and 
in  deranged  thyroid  and  hypophysial  function.  Tests  with  the 


170  BLOOD    AND    URINE    CHEMISTRY 

subcutaneous  injection  of  epinephrin  showed  that  a  marked  hy- 
perglycemia occurs  and  reaches  its  maximum  in  one  hour  and 
then  subsides  as  rapidly  as  it  arose,  the  whole  reaction  lasting  two 
hours.  There  is  no  relationship  between  the  degree  of  alimentary 
hyperglycemia  and  the  degree  of  epinephrin  hyperglycemia.  Yet 
when  the  alimentary  glucose  test  shows  certain  abnormalities  in 
the  character  of  the  blood  sugar  reaction,  these  same  abnormali- 
ties are  reproduced  in  the  epinephrin  curve.  The  reaction  of 
epinephrin  on  sugar  metabolism  is  independent  of  its  other  re- 
lations; there  is  no  constant  relation  between  the  hyperglycemia, 
the  vascular  effects  and  the  diuresis.  Hammann  and  Hirschman 
showed  that  epinephrin  has  no  effect  011  the  renal  permeability 
for  glucose.  It  was  also  shown  that  atropin  diminishes  the  effect 
of  epinephrin  on  the  mobilization  of  sugar;  pilocarpin  increases 
the  effect.  When  atropin  acts  in  this  respect  as  a  marked  de- 
pressant, pilocarpin  has  little  or  no  influence;  when  atropin  acts. 
slightly,  pilocarpin  greatly  exaggerates  the  epinephrin  effect. 
In  our  discussion  of  the  etiology  of  the  disease  diabetes  and  the 
experimental  data  of  later  years  that  have  thrown  so  much  light 
upon  this  question,  we  must  not  forget  to  note  the  pioneer  work 
in  this  field  that  laid  the  basis  for  our  present  scientific  methods. 
Von  Noorden's  work  on  diabetes,40  even  though  his  theoretical 
foundation  has  been  much  disputed,  did  much  to  intensify  the 
interest  in  its  study.  Von  Me  ring  and  Minkowski,  as  early  as 
1890,  laid  down  certain  truths  about  this  disease  to  which  the 
later  work  of  Allen  possibly  is  attributable.  Others  who  did 
much'  in  this  field  were  Lepine,  Arthaud,  Butte,  Remond,  Hedon, 
Gley,  Thiroloix,  Lancereaux,  in  France;  dc  Dominicis,  de  Rinzi, 
Reale-,  Gaglio,  Caparelli,  in  Italy:  Aldehoff,  Sandmeycr,  Markuse, 
Weintraub,  Seelig,  in  Germany;  V.  Harlcy,  in  England;  and 
Schabad,  in  Russia.  The  work  of  Minkowski  on  dogs  seemed  to 
crystallize  all  the  previous  thoughts  and  data  into  a  concrete 
whole.  It  might  be  interesting  to  note  that  the  train  of  symptoms 
which  follows  removal  of  all  or  part  of  the  pancreas  in  dogs  is 
about  as  follows:  polyphagia,  polydipsia,  hyperglycemia,  destruc- 
tion of  albumin,  loss  of  weight,  appearance  of  acetone,  diacetic 
acid,  bcta-oxybutyric  acid,  ammonia  in  the  urine,  death  in  coma, 

«von  Xoordcn:      Die  Zuckerkrankheit,   Berlin,   1912. 


BLOOD   SUGAR 


177 


with,  of  course,  glycosuria  at  first  quite  abundant,  later  dwindling 
down  as  the  source  is  depleted. 

It  might  be  well  at  this  point  to  review  some  of  the  facts  of 
normal  and  abnormal  physiological  chemistry  so  far  as  the  source 
and  destiny  of  sugar  in  the  body  is  concerned,  after  which  we 
can  more  intelligently  survey  the  various  classes  of  conditions 
grouped  as  " glycosurias. "  A  glance  at  the  diagrams  (Figs.  61, 
62,  63)  will  show  how  the  sugar  in  the  body  that  is  derived  princi- 
pally from  the  amount  of  carbohydrates  ingested,  is  utilized  under 


Liver 


Portal  vein 

Intestinal  tract 


Systemic  circulation 
Glucose  concentration 

003% 
Kidneys 


•~No  sugar  m  the  urine 


Muscle  fibre 
'_3  Sugar  utilized 
p  Glycogen  •»*<- 


Fig.  61.  —  Diagram  illustrating  normal  sugar  metabolism.      (From  Forcheimer:     " 
sis  of  Internal  Diseases.") 


Therape 


'emic  Circulation 
lucose  Concentration 
O./&  %  and  more 


Kidneys 


Intestinal  tract 


Fig.  62. — Diagram  illustrating  the  nonutilization  of  sugar  in  rl'abetes.   (From  Forcheitnpr: 
"Therapeusis  of  Internal  Diseases.") 

normal  conditions.  These  carbohydrates  are  principally  starches 
and  sugars.  The  evolution  of  carbohydrates  in  the  body  takes 
place  by  the  action  of  intestinal  enzymes,  converting  them  "into  the 
six  hexoses  or  carbon  sugars  which  find  their  way  as  such  into  the 
portal  vein  and  thence  into  the  liver.  In  the  liver  the  sugar  is 
formed  into  glycogen  and  the  excess  sweeps  out  into  the  blood  stream 
via  the  hepatic  vein  as  sugar.  It  is  only  und  ^r  exceptional  con- 
ditions that  the  glycogen  stored  in  the  liver  is  called  upon  for 
more  fuel  (sugar).  Experimentally,  of  course,  it  can  be  shown 


178 


BLOOD    AND    URINE    CHEMISTRY 


that  this  is  true  by  the  finding  of  much  more  sugar  in  the  portal 
vein  than  in  the  hepatic  vein.  The  liver  function  is  possibly  that 
of  a  screen,  holding  back  a  large  part  of  the  sugar  and  allowing 
the  minor  part  to  go  on  its  way  peripherally.  Of  course  it  must 
not  be  forgotten  that  this  sugar  in  the  circulation  is  not  always 
immediately  demonstrable,  i.  e.,  it  is  stored  up  in  muscle  as  in 
liver  as  glycogen.  The  liver  is  a  veritable  reservoir  of  glycogen. 
It  is  claimed  that  14  per  cent  of  the  weight  of  the  liver  is  fur- 
nished by  its  glycogen  content.  Von  Noorden  very  aptly  calls 
the  liver  a  "glycogen  reservoir"  and  the  muscles  a  "glycogen  de- 
pot." He  means  by  this  that  while  the  percentage  of  glycogen 
in  liver  and  in  muscle  by  weight  is  possibly  identical,  the  call  for 
glycogen  or  dextrose  is  first  upon  the  liver  and  secondly  upon 
the  muscles.  Another  consideration  of  this  interesting  fact 


Circulation 
ucose  concentration 


illustrating  excessive  formation  of  sugar  through  nonrctention   of  glyc 


iK.   63.— Diai 

gen  in  the  liver.     (From  Forchcimer:  "Therapeusis  of  Internal  Diseases.") 


would  be  that  the  union  of  the  glycogen  with  the  liver  cells  is 
not  near  so  firm  as  the  union  of  the  muscle  cells  with  their 
glycogenic  visitor.  There  is  another  source  of  sugar,  namely,  pro- 
tein. This  was  disputed  for  a  long  time  but  now  proof  seems  to 
be  undeniable.  Protein  is  transformed  into  ammo-acids  such  as 
glycocoll  alanine,  aspartic,  and  glumatic  acids,  and  these  in  turn 
go  over  into  dextrose.  This  was  originally  proved  by  the  experi- 
mental fact  that  animals  fed  exclusively  upon  protein  and  fat 
store  up  large  amounts  of  glycogen. 

A  very  elaborate  research  on  this  question  can  be  found  in  the 
work  of  Kuobc.47  Von  Mering  and  Minkowski,48  in  their  excellent 
work  on  experimental  diabetes,  rather  clearly  prove  the  dcriva- 


7Kui-lx:     Reported  in   Pflv 
'von    Mering   and    Minkov 


f.   d.  gcs.   Physiol.,   1903.  vol.  xcvi,  p.   1. 
f.    d.    ges.    Physiol.,    1904,   vol.    cvi.   p.    160. 


BLOOD    SUGAR  179 

tion  of  some  of  the  sugar  in  the  urine  from  proteins  of  the  food 
and  tissues  and  from  fat.  For  the  first  few  days  after  removal 
of  the  pancreas,  it  appears  probable  that  the  sources  of  the  sugar 
are  proteins  and  fats  of  the  body.  The  most  important  point 
from  the  standpoint  of  the  physiologist,  hoAvever,  is  the  constant 
relation  between  the  output  of  nitrogen  and  sugar,  the  so-called 
D  :N  ratio  of  experimental  diabetes.  From  the  D  :N  ratio  it  is  safe 
to  conclude  that  dextrose  is  partially  derived  from  protein. 

A  recent  and  most  important  work  bearing  upon  this  point  of 
the  derivation  of  glucose  from  protein  is  that  of  N.  W.  Janney,49 
who  states  that  the  serious  objections  open  to  the  data  on  this 
line  of  work  in  the  past  are  based  upon  the  fact  that  the  feeding 
experiments  are  not  conclusive,  inasmuch  as  it  cannot  be  demon- 
strated that  all  the  food  material  is  digested  and  absorbed  and 
that  all  the  glucose  arising  from  this  material,  and  no  more, 
originates  from  the  protein  that  has  been  given  the  subject.  It 
must  be  remembered,  too,  that  in  diabetes  mellitus  a  certain  amount 
of  oxidation  takes  place  and  that  the  capacity  of  the  average 
human  diabetic  to  utilize  glucose  frequently  may  undergo  con- 
siderable daily  variation,  even  when  the  diet  remains  the  same. 
It  is  also  possible,  states  Janney,  that  the  glucose  originating 
from  food  protein  may  be  in  part  synthetically  used  in  the  for- 
mation of  various  body  substances  or  may  be  deposited  as  glyco- 
gen.  Again  it  is  inadvisable  to  use  fasting  diabetics  for  these  ex- 
periments because  starvation  increases  the  ability  of  the  organ- 
ism to  oxidize  glucose.  Another  and  contrary  effect  of  feeding 
quantities  of  sugar-forming  proteins  to  diabetics  is  to  lower  the 
tolerance  of  the  organism  for  glucose.  This  is  very  evident  from 
data  accumulated  experimentally  by  Mohr.  Another  disturbing 
factor  in  using  the  human  diabetic  is  the  fact  that  muscular  ex- 
ercise may  decrease  the  glycosuria  under-  some  circumstances  and 
increase  it  under  others.50  The  difficulty  of  preventing  diabetics 
from  breaking  diet  is  the  chief  cause  of  the  error  in  human  ex- 
periments. Using  dogs  with  extirpation  of  the  pancreas  has  been 
attempted,  in  these  experiments,  but  this  is  a  poor  method  be- 
cause extirpation  of  the  pancreas  in  dogs  is  followed  by  severe 
affections  of  the  digestive  system. 

4".Tanney,   N.   W.:     Arch.   Int.  Med.,  Nov.   15,   1916,  vol.  xviii,  No.   5,  p.   584. 
•wvon  Noorclen:      Die  Zuckerkrankhcit,    1912,  ed.   6,  p.   100. 


180  BLOOD   AND    URINE    CHEMISTRY 

With  these  facts  in  mind,  Janney  tried  out  these  experiments 
in  the  course  of  cases  of  phlorizin  diabetes,  developing  a  technic 
by  which  the  extent  of  protein  conversion  into  glucose  could  be 
followed  with  considerable  accuracy.  The  details  of  this  technic 
may  be  found  in  his  previous  publications.51  Janney  mentions  a 
few  facts  about  phlorizin  diabetes  which  has  been  so  well  studied 
of  late  years  by  Lusk  and  others  (see  page  188  for  further  particu- 
lars on  phlorizin).  Where  phlorizin  is  given  to  dogs,  diabetes  de- 
velops, the  reserve  of  carbohydrates  in  the  body  is  used  up,  and  in 
the  fasting  state  the  glucose -appearing  in  the  urine  bears  a  con- 
stant relation  to  the  urinary  nitrogen,  this  so-called  glucose- 
nitrogen  ratio  averaging  3.4  to  1.  Glucose  administered  to  such 
dogs  is  quantitatively  excreted.52  Glucose  arising  from  nontoxic 
ingested  substances  fails  to  be  stored  up  but  appears  in  the  urine 
as  such.  Janney 's  experimental  work  shows  that  it  is  probable 
that  all  the  glucose  arising  from  protein  fed  to  phlorizined  dogs  is 
excreted  in  their  urine.  This  demonstrates  that  the  urinary  glu- 
cose and  nitrogen  of  fasting  phlorizined  dogs,  which  quantita- 
tively excrete  ingested  sugar,  bear  the  same  relation  to  each  other 
as  the  extra  glucose  arising  from  these  animals'  own  protein  in- 
gested by  other  phlorizined  dogs  does  to  the  nitrogen  contained  in 
these  proteins.  The  sugar  excreted  under  these  circumstances 
represents  the  maximal  amount  formed  from  the  animals'  body 
proteins. 

Janney 's  work  showed  that  glucose  formation  from  protein  is 
the  same  in  diabetes  mcllitus  as  in  phlorizin  diabetes.  He  found 
that  isolated  proteins  yielded  large  amounts  of  glucose  in  metabol- 
ism, varying  from  48  to  80  per  cent  according  to  the  protein  ex- 
amined. Contrary  to  existing  opinions,  the  animal  or  vegetable 
origin  of  proteins  bears  no  relationship  to  their  ability  to  produce 
glucose  in  the  animal  organism,  this  function  being  found  to  be 
mainly  dependent  on  the  amounts  of  sugar-yielding  amino-acids 
entering  into  the  constitution  of  these  various  proteins.  Janney 's 
studies  on  glucose  formation  from  body  proteins  demonstrate  that 
body  proteins  of  man  and  animals  yield  about  58  per  cent  of  glu- 
cose in  metabolism.  The  nitrogen  of  these  proteins  bears  about 


••'Janney,  N.  W. :     Jour.   Riol.   Chcm.,   1915,  vol.  xx,  p.   321. 

Janney,   N.   W.,  and   Csonka,   F.  A.:     ibid.,  vol.   xxii,   p.   203. 

lanney,   N.    W.,   and    I'.latherwick,    N.    R.:      ibid.,    vol.   xxiii,   p.   77. 
"Ringer,    A.    I.:      Jour.    P.iol.    Chem.,    1912,    vol.    xxii,    p.    422. 


BLOOD   SUGAR  181 

the  relation  of  3.6  to  1  to  the  glucose  formed  from  them.  This 
definite  establishment  of  the  glucose-nitrogen  (D  :N)  ratio  is  of 
value  in  the  prognosis  of  diabetes.  Cases  showing  a  high  urinary 
D:N  ratio  averaging  3.4  to  1,  are  to  be  regarded  as  grave.  The 
lower  the  ratio,  the  more  favorable  the  prognosis.  As  the  glucose 
eliminated  by  the  fasting  diabetic  is  of  protein  origin,  sugar  forma- 
tion from  fat  does  not  take  place  to  any  great  extent  in  this  dis- 
ease. 

Janney  also  reported  the  results  of  glucose  formation  from  pro- 
tein foods,  using  the  same  technic.  In  von  Noorden's  food  tables 
for  diabetics,  glucose  formation  from  protein  has  not  been  taken 
into  account. .  By  adding  the  amounts  of  glucose  yielded  in  meta- 
bolism by  the  proteins  of  a  given  food  to  its  carbohydrate  content, 
it  is  possible  to  ascertain  the  actual  amount  of  sugar  both  set  free 
and  formed  in  the  metabolism  of  such  foods.  Janney  also  found 
from  experimental  studies  that  the  various  proprietary  protein 
foods  present  no  advantages  over  equal  amounts  of  bread  when 
fed  to  diabetics,  as  the  large  amount  of  protein  present  leads  to 
the  formation  of  considerable  glucose  in  metabolism. 

When  we  come  to  the  consideration  of  the  possibility  of  the 
derivation  of  dextrose  in  the  body  from  fat,  we  have  not  yet  had 
sufficient  experimental  or  chemical  proof.  We  know  that  in  plant 
life  carbohydrates  seem  to  undergo  transformation  into  fat,  still 
it  has  not  yet  been  clearly  proved  in  the  animal  economy.  Foster, 
in  his  excellent  work,53  calls  attention  to  this  point,  quoting  from 
analyses  of  nuts  by  du  Sablon.54  The  figures  are  parts  per  100. 

OIL  GLUCOSE 

On  July  6,  these  nuts  showed     3  7.6 

Aug.  1,      "       "          "16  2.4 

Sept.  1,      "        "          "        59  0 

Oct.    4,      "        "          "        62  0 

Again  we  have  the  example  of  the  germination  of  seeds  with  the 
disappearance  of  fats  and  the  appearance  of  carbohydrates.  These 
facts  of  plant  physiological  chemistry  do  not  hold  good,  however, 
with  the  animal  organism.  Fats  are  split  up  into  glycerol  and  the 
fatty  acids,  but  so  far  there  is  no  proof  of  their  ultimate  conversion 
into  sugar.  We  know  now  that  the  increase  of  fats  in  the  diet  of  a 


^Foster,  N.   B. :     Diabetes  Mellitus,   T.   B.   J.ippincott  Company,   1915. 
Mdu    Sablon:      Compt.    rend.,    1896,   vol.    cxxiii,   p.    1084. 


182  BLOOD   AND    URINE    CHEMISTRY 

diabetic  docs  not  increase  the  amount  of  sugar  in  the  urine.  The 
von  Noorden  idea  on  diabetes  has  been  shown  to  be  erroneous,  par- 
ticularly with  reference  to  the  fact  that  sugar  in  any  quantity  re- 
sults from  the  catabolism  of  fat. 

The  ultimate  fate  of  dextrose  in  the  body  is  not  clearly  and 
definitely  understood.  While  we  have  many  theories  and  many 
experiments,  we  cannot  place  our  finger  firmly  and  definitely  upon 
the  pivotal  point  of  the  change  of  a  normal  person,  say,  into  a 
diabetic.  As  Foster55  truly  says:  "At  the  present  time  we  must 
confess  that  we  are  quite  without  sufficient  data  to  form  any  clear 
conception  of  the  breakdown  of  the  glucose  molecule,  and  it  is  prob- 
able in  the  initial  step  in  the  destruction  of  glucose  that  the  es- 
sential deviation  of  the  diabetic  from  the  normal  becomes  manifest. 
Certainly  the  diabetic  organism  is  usually  able  to  handle  the  cleav- 
age products  of  glucose.  The  inability  to  effect  the  first  cleavage 
might  rest  in  a  change  in  the  cell  where  oxidation  is  effected  or  in 
the  absence  of  an  activator.  In  the  light  of  our  knowledge  of  other 
vital  processes,  we  must  assume  the  dependence  of  these  changes 
upon  zymases  elaborated  in  one  class  of  cells,  perhaps  the  muscle, 
and  in  order  to  effect  their  function  probably  requiring  an  acti- 
vator or  hormone  secreted  perhaps  by  quite  remote  and  different 
cells. 

Joslin54  states  that  he  considers  every  patient  a  diabetic  un- 
til the  contrary  is  proved,  who  has  sugar  in  his  urine  demon- 
strable by  any  of  the  common  tests.  At  this  point  it  must  be 
remembered  that  glycosuria  simply  means  sugar  in  the  urine  in 
undue  quantities.  How  this  may  be  brought  about  independent 
of  the  disease  diabetes  mcllitus,  we  shall  now  consider.  Every 
medical  man  is  familiar  with  the  classic  experiment  of  Claude 
Bernard,1"'5  who,  as  early  as  1845,  induced  glycosuria  in  rabbits 
by  his  piqnrc  experiment,  i.  c.,  the  insertion  of  a  steel  stylet  into 
the  brain  of  a  rabbit.  Bernard  thrust  his  stylet  into  the  inferior 
part  of  the  calamus  scriptorius.  This  glycosuria  persisted  sev- 
eral hours  provided  the  animals  were  in  a  normal  state  of  nutri- 
tion. It  was  completely  inhibited  if  the  animal  had  fasted  for  a 
period  prior  to  the  experiment,  in  other  Avords,  if  its  glycogcn 

•'•M'dstcr,   X.    I!..:      Dialers   Mdlitus,  J.    15.    Lippincott   Company,    1915. 

"^Bernard,  Claude:  !>»•  fon^ine  du  stu-ri-  clans  lYronmr.ic  animate,  Paris.  1S4S;  also 
L,ccons  sur  le  diahetc  ct  la  glycogncsc  animate,  J.  It.  Ballicrc  et  fiis,  1877,  p.  576. 


BLOOD   SUGAR  183 

had  been  practically  released  and  burned  up  from  its  "reser- 
voir" in  the  liver.  The  blood  sugar,  as  well  as  urine  sugar,  rises 
in  puncture  diabetes.  Bernard  also  showed  that  nerve  stimula- 
tion had  a  profound  influence  in  these  experiments.  The  stimula- 
tion of  the  splanchnics  by  the  stylet  in  the  so-called  "diabetic 
center,"  of  course,  causes  the  liberation  of  the  glycogen  in  liver 
and  its  undue  appearance  in  blood,  thence  into  urine.  Stimula- 
tion of  the  cut  vagi  after  puncture  of  the  calamus  scriptorius 
caused  the  following :  stimulation  of  the  central  stump  induced  gly- 
cosuria;  stimulation  of  the  peripheral  stump  did  not.  Eckhard56 
showed  that  division  of  the  vagus  and  electrical  stimulation  will 
cause  temporary  glycosuria  even  several  days  after  the  nerve  is 
divided.  Sugar  may  also  be  caused  to  appear  in  the  urine  by 
cutting  the  lower  cervical  or  upper  thoracic  sympathetic  ganglia, 
as  shown  by  Schiff.57 

It  is  also  noteworthy  that  the  adrenal  bodies  are  somehow  con- 
cerned in  glycogenolysis  and  glycosuria.  It  was  Herter58  who 
first  showed  that  painting  the  pancreas  with  adrenal  extract 
caused  glycosuria.  The  application  of  adrenal  extracts  has  a 
profound  influence  upon  hyperglycemia  and  glycosuria.  We 
have  alluded  before  to  the  fact  that  the  liver  combination  with 
glycogen  is  not  nearly  so  firm  as  the  muscle  combination,  yet 
the  injection  of  epinephrin  into  the  blood  causes  the  liberation 
of  sugar  more  quickly  from  the  muscles  than  from  the  liver,  ac- 
cording to  Kutschmer.59  When  animals  are  made  glycogen-free 
by  fasting  and  the  use  of  phlorizin,  the  use  of  epinephrin  does 
not  produce  glycosuria,  indicating  that  this  too,  like  the  piqure 
of  Bernard,  is  a  form  of  glycogenolysis.  It  is  a  fact  that  piqure 
glycosuria  does  not  occur  if  the  adrenals  are  previously  removed, 
indicating  the  influence  of  these  bodies  upon  this  experiment. 

Studies  have  been  made  from  time  to  time  on  the  blood  sugar 
in  hyperthyroidism,  owing  to  the  fact  that  spontaneous  glycosuria 
is  so  frequently  observed  in  patients  suffering  with  ttiis  disease. 
These  studies  have  led  to  conflicting  results.  We  mention  them 
in  order  to  show  the  alertness  of  mind  of  those  who  have  so  much 


56Eckhard:     Beitr.   z.    Anat.   u.    Physiol.,    1896,  vol.   iv,   p.    4. 

57Schiff:      Untersuchung    iiber    die    Zuckerbildung    in    der    Leher    u.    den    Einfluss    des 
Nervensystems   auf   die   Erzeugung   des   Diabetes,    Wiirzburg,    1859. 
58Herter:     Medical   News,   1902. 
89Kutschmer:     Arch.  f.   exper.   Path.  u.  Pharmakol.,   1907. 


184  BLOOD   AND    URINE    CHEMISTRY 

interest  in  this  subject,  especially  with  reference  to  the  role  of 
the  internal  secretions  in  blood  sugar  metabolism.  Tachau  and 
Flesch60  found  an  alimentary  hyperglycemia  in  some  cases  but  not 
in  others.  In  forty  cases  the  latter  investigator  reported  not  a 
single  case  of  spontaneous  hyperglycemia.  Geyelm01  in  twenty- 
seven  cases  of  hyperthyroidism,  found  90  per  cent  of  the  moderate 
and  severe  cases  with  hyperglycemia  (two  hours  after  100  gms. 
of  glucose).  Denis  and  Aub62  undertook  an  investigation  of 
blood  sugar  in  hyperthyroidism,  dealing  with  the  effects  of  car- 
bohydrate ingestion  of  persons  suffering  from  this  disease.  Coin- 
cident with  these  experiments  they  made  observations  on  the 
gaseous  metabolism  of  these  patients,  with  the  idea  of  establish- 
ing, if  possible,  some  relation  between  the  increase  in  metabolism 
found  in  this  condition  and  the  effect  produced  011  the  blood 
sugar  level  by  the  ingestion  of  carbohydrate.  In  these  subjects 
the  " fasting"  blood  sugar  showed  a  minimum  value  of  0.090  per 
cent,  a  maximum  of  0.12  per  cent,  and  an  average  value  of  0.10 
per  cent.  They  found  that  in  most  normal  persons  the  ingestion 
of  100  gms.  of  glucose  and  50  gms.  of  bread  causes  no  increase 
in  blood  sugar  two  hours,  or  even  one  hour  after  breakfast. 
Two  exceptions  to  this  statement  were  found  in  their  series : 
two  nurses  showed  an  unmistakable  increase  which  had  not  dis- 
appeared in  two  hours.  They  were  engaged  in  work  of  a  most 
exacting  nature  and  were  in  need  of  a  vacation.  Both  showed 
also  slight  glycosuria.  This  is  in  line  with  the  observations  of 
Graham63  who  in  a  series  of  experiments  on  himself,  demon- 
strated the  fact  that  when  in  good  condition  the  blood  sugar  re- 
gains its  original  level  one  to  one  and  one-half  hours  after  in- 
gestion of  100  gms.  of  glucose,  whereas  under  conditions  which 
cause  fatigue,  three  to  four  hours  elapse  before  the  fasting  blood 
sugar  level  is  again  reached.  In  thirteen  cases  of  hyperthy- 
roidism, only  five  showed  blood  sugar  values  above  normal. 
These  five  were  outpatients  who  had  been  previously  subjected 
to  observations  on  the  respiratory  apparatus,  consequently  an 
emotional  factor  might  have  been  involved  in  the  cases  in  which 


00Tachau:     Deutsch.  Arch.   f.   klin.   Med.,   1911,   vol.   cxiv.  p.  445. 

Flesch:      Beitr.  z.  klin.   Chir.,   1912,  p.  236. 
""Geyelin:     Arch.   Int.   Med.,   1915,  vol.  xvi,  p.   975. 
"Denis  and   Aub:     Arch.   Int.   Med.,   1917,  vol.   vi,  p.   964. 
•"Graham:     Jour.    Physiol.,   1916,  vol.   1,   p.   285. 


BLOOD   SUGAR  185 

hypcrglycemia  was  noted ;  in  fact,  the  patient  showing  the  highest 
degree  of  blood  sugar,  was  much  excited  by  the  respiration  ob- 
servations and  by  the  prospect  of  venipuncture.  It  is  obvious 
that  these  single  blood  sugar  determinations  made  on  fasting  pa- 
tients, even  when  the  emotional  factor  was  disregarded,  did  not 
indicate  the  constant  occurrence  of  a  fasting  hyperglycemia  in 
hyperthyroidism.  In  seventeen  cases  of  hyperthyroidism  blood 
sugar  determinations  were  made  before,  and  at  intervals  of 
one,  two,  and  four  hours  after  the  ingestion  of  100  gms.  glucose 
and  50  gms.  of  bread.  They  found  that  under  these  conditions 
fasting  hyperglycemia  is  very  rare  and  that  alimentary  hyper- 
glycemia lasting  in  some  cases  for  four  hours  after  the  ingestion 
of  the  carbohydrates  is  usually  the  rule.  Clinically  it  has  been 
observed  that  thyroid  administration  frequently  causes  the  sub- 
ject to  show  an  alimentary  glycosuria.  The  experiments  of 
Cramer  and  Krausef4  in  which  it  was  shown  that  the  administra- 
tion of  thyroid  to  rats  and  cats  caused  an  almost  complete  disap- 
pearance of  glycogen  from  the  liver,  would  seem  to  explain  the 
frequent  occurrence  of  glycosuria  in  hyperthyroidism  as  due 
to  a  lack  of  ability  on  the  part  of  the  patient  to  store  ingested 
carbohydrate.  On  this  assumption,  assuming  also  that  the  in- 
crease in  'basal  metabolism  gives  a  measure  of  the  excess  of  thy- 
roid secretion,  it  would  follow  that  in  cases  in  which  the  basal 
metabolism  is  high,  alimentary  hyperglycemia  and  glycosuria 
would  also  be  more  readily  induced  and  of  a  more  severe  type: 
Denis  and  Aub,  however,  were  not  able  to  confirm  this  hypothesis. 
The'ir  results  also  showed  the  absence  of  any  marked  effect  pro- 
duced on  blood  sugar  by  the  administration  of  thyroid.  There 
was  nothing  to  show  that  there  was  any  relationship  between 
the  severity  of  the  intoxication  (as  measured  by  the  percentage 
increase  over  normal  of  the  basal  metabolism)  and  the  occurrence 
of  hyperglycemia.  In  a  number  of  cases  they  found  that  after 
improvement  of  the  patient's  condition  by  rest  or  by  operation 
the  alimentary  hyperglycemia  was  of  a  much  lower  grade  than 
that  induced  by  the  same  test  meal  given  before  treatment. 
Blum65  in  1901  shows  that  the  injection  of  adrenalin  subcu- 


MCramer  and   Krause:      Proc.    Roy.    Soc.,   London,    1913.  vol.   Ixxxvi,   p.    550. 
"sBlum,   F. :     Deutsch.   Arch.   f.   klin.   Med.,   1901,  vol.   bod,  p.   146. 


186  BLOOD   AND   URINE    CHEMISTRY 

taneously  gives  rise'  to  glycosuria.  Metzger00  proved  that  gly- 
cosuria  of  this  kind  results  from  hyperglycemia.  Adrenalin  gly 
cosuria  can  be  produced  in  all  laboratory  animals  including  the 
frog.  The  dose  is  small,  0.01  mgm.  with  glycosuria  in  two  hours, 
lasting  usually  about  three  hours.  Blum  at  first  believed  that 
adrenalin  glycosuria  occurs  in  animals  starved  entirely  glycogen- 
free;  he  later  reversed  this  opinion.  Herter  and  Richards  also 
showed  that  prolonged  fasting  with  phlorizin  poisoning  reduced 
dogs  to  a  condition  in  which  adrenalin  gave  rise  to  no  glycosuria. 
Allen's  idea  is  that  adrenalin  under  suitable  conditions  may  cause 
formation  of  glycogen  from  protein.  Pollak07  made  rabbits 
glycogen-free  by  starvation  and  strychnin,  and  then  by  increas- 
ing doses  of  adrenalin  was  able  to  bring  about  a  formation  of 
new  glycogen.  Adrenalin  does  not  produce  glycosuria  in  normal 
animals  which  have  been  made  glycogen-free.  Adrenalin  will 
probably  produce  glycosuria  in  glycogen-free  diabetic  animals, 
or  will  cause  an  excretion  of  sugar  in  excess  of  the  quantity  of 
glycogen  present.  Animals  nearly  or  totally  depancreatized  are 
much  more  prone  to  most  forms  of  glycosuria  than  normal  ani- 
mals. It  has  been  demonstrated  by  Allen  that  piqure  will  pro- 
duce glycosuria  in  these  animals  when  they  are  so  far  gone  that 
spontaneous  glycosuria  has  ceased,  and  when  a  nondiabetic  ani- 
mal would  certainly  show  no  glycosuria.  Allen  believed  that  it  is 
probable  that  the  action  of  adrenalin  will  be  found  similar. 
Again  Pollak  found  that  the  repeated  injection  of  adrenalin  con- 
tinued to  cause  hyperglycemia,  but  for  some  unknown  reason  the 
permeability  of  the  kidneys  was  altered  so  that  sugar  failed  to 
appear  in  the  urine.  Ringer  proved  that  at  the  height  of  phlo- 
rizin glycosuria,  adrenalin  caused  no  increase  of  sugar  excretion. 
Kppinger,  Falta  and  Rudinger08  asserted  that  after  thyroidectomy 
with  preservation  of  the  parathyroids,  adrenalin  produced  no 
glycosuria.  The  presence  or  absence  of  the  thyroid  is  not  a  de- 
termining factor  in  adrenalin  glycosuria.  Ascher19  found  that 
hypophysectomized  dogs  react  very  slightly  to  adrenalin,  and 
show  no  glycosuria.  Schwarz70  found  that  epinephrectomized 

06Metzgcr:   Munchen.   med.   Wchnschr.,    1902,   p.    478. 

n7Pollak:      Arch,    exper.    Path.    u.    Pharm.,    1909,    vol.    Ixi,    p.    149. 

""Kppingcr,   Kalta  and   Rmlinj?cr:      Ztschr.   f.   klin   Med.,    1908,   Ixvi,    1-52. 

""Ascher:      Central!),    f.    Physiol.,    1910,   vol.    xxiv,   p.    927-9. 

'"Schwarz:     Pflueger  Arch.,   1910,  vol.  cxxxiv,  p.  259. 


BLOOD   SUGAR  187 

rats,  some  time  after  the  operation,  acquire  an  extreme  sensi- 
tiveness to  adrenalin.  In  dogs  epinephrectomy  is  followed  by 
glycosuria  when  adrenalin  is  applied.  Pollak71  found  that 
adrenalin  glycosuria  occurs  after  cutting  the  splanchnic  nerves 
of  both  sides.  Velich72  found  that  removal  of  the  liver  prevents 
adrenalin  glycosuria  in  frogs. 

As  pointed  out  already,  Mayer73  proved  that  after  removal  of 
both  adrenals,  the  sugar  puncture  no  longer  produces  glycosuria. 
Eppinger,  Falta  and  Rudinger  believed  that  the  glycosuria  from 
the  piqure  is  due  to  a  discharge  of  adrenalin  from  the  chromaf- 
fin  system.  In  general  it  may  be  said  that  we  know  very  little 
more  about  the  adrenal  function  than  Addison.  "The  mystery 
of  the  adrenals  remains,"  says  Allen  in  his  masterly  review  of 
this  question.  "We  know  that  animals  survive  epinephrectomy 
because  of  accessory  adrenals  which  may  be  situated  at  as  far  dis- 
tant a  point  as  the  epididymis ;  we  know  that  adrenal  grafts 
maintain  an  animal  after  epinephrectomy  provided  the  grafts 
contain  medullary  substance — -not  so  if  they  contain  only  cortical 
substance ;  we  know  that  continuous  carotid  cross-transfusion  be- 
tween an  epinephrectomized  and  a  normal  animal  results  in 
the  death  of  the  former  and  the  survival  of  the  latter."  It  is 
not  a  matter  of  transmission  of  adrenalin  impulse  along  nerve 
fibers.  All  kinds  of  speculative  theories  have  been  advanced, 
but  Allen  states  in  answer  to  all  of  them  that  there  is  possibly 
something  here,  outside  the  present  knowledge  of  physiology,  as 
unexplainable  as  nervous  phenomena  before  nerves  were  known, 
^pr  as  internal  secretory  phenomena  before  internal  secretion  was 
known. 

It  might  be  well  to  mention  the  fact  that  not  only  actual  punc- 
ture of  the  calamus  scriptorius  causes  glycosuria  transitoria ;  in- 
crease in  intracranial  pressure  or  traumatic  pathological  condi- 
tions of  other  kinds  may  do  so.  One  of  us74  reported  an*observa- 
tion  of  severe  and  transitory  glycosuria  in  a  case  of  cerebral 
hemorrhage  due  to  an  intraventricular  hemorrhage.  In  this  case 
the  glycosuria  lasted  several  days  and  disappeared,  possibly  co- 


71Pollak:     Arch.   f.   exp.   Path.   u.   Pharm.,   1909,  vol.   Ixi,   p.    149. 
"Velich:      Virchows   Arch.,    1906,   vol.   Ixxxiv,   p.    345. 
73Mayer:     Compt.   rend.   Soc.   Biol.,    1908,  vol.   i,  p.   219. 
74Gradwohl,   R.   B.   II.:     Philadelphia  Med.  Jour.,  April  22,    1899. 


188  BLOOD    AND    URINE    CHEMISTRY 

incidciitly  with  the  using  up  of  all  the  glycogcn  in  the  liver  and 
muscles.  Autopsy  later  showed  the  clot. 

It  is  claimed  by  AVoodyatt75  that  various  other  drugs,  such  as 
phosphorus,  carbon  monoxide,  hydrazine,  arsenic,  etc.,  may  cause 
glycosuria  by  causing  the  increased  glycogenolysis  alluded  to 
above. 

Another  interesting  form  of  glycosuria  is  that  caused  by  the 
injection  of  phlorizin,  called  "phlorizin  diabetes."  References 
to  this  interesting  condition  can  be  found  in  the  literature.76 

Phlorizin  is  a  glucoside  which  can  be  extracted  from  the  bark 
of  apple  and  cherry  trees.  In  1886,  von  Mering  established  the 
fact  that  the  administration  of  this  drug  to  dogs,  geese,  and  rab- 
bits induced  glycosuria.  If  you  give  a  dog  1  gm.  of  phlorizin 
per  kilo  of  body  weight,  in  a  few  hours  you  will  observe  at  least 
10  per  cent  of  urine  sugar.  The  blood  sugar  will  not  rise.  In 
other  forms  of  diabetes  except  this  variety,  you  have  hyperglyccmia. 
The  sugar  will  persist  in  the  urine  as  long  as  you  give  the  phlorizin. 
All  sugar  as  it  is  formed  in  the  body  goes  out  in  the  urine  as 
sugar.  It  is  claimed  by  some  that  in  this  condition  the  phlorizin 
ingested  simply  throws  down  the  barrier  of  the  kidney  filter ;  in 
other  words,  that  the  kidneys  are  made  absolutely  and  completely 
permeable  to  sugar  by  some  alteration  in  the  secretory  epithclia. 
This  overflow  of  sugar  from  the  blood  causes  a  deficit  which  is 
supplied  by  the  pouring  out  of  more  glycogen  from  liver  and 
muscles  into  the  circulating  blood  as  sugar,  until  all  is  used  up. 
It  is  for  this  reason  that  there  is  no  undue  accumulation  of  sugar 
in  the  blood.  Here  again  we  wish  to  allude  to  von  Noorden's 
ideas,  that  at  this  juncture  he  thought  the  supply  of  sugar  in 

"Woodyatt,  R.  T. :  quoted  in:  Wells'  Chemical  Pathology,  Philadelphia  and  London, 
second  edition,  1914,  p.  573. 

•«von  Mering:  Cong.  f.  inn.  Med.,  1886,  vol.  clxxxv;  Ztschr.  f.  klin.  Med.,  1889, 
vols.  xiv  and  xvi. 

Moritz   and    Prausnitz:   Ztschr.    f.    Riol.,    1891,   vol.   xxvii. 

Kuelz  and  Wright:     Ztschr.   f.   Riol.,   1890,  vol.   xxvii. 

Cremer  and  Ritter:     Ztschr.    f.    Riol.,    1892,   vol.   xxviii. 

Minkowski:      Arch.    f.    exper.    Path.    u.    Pharmakol.,    1893,    vol.    xxxi. 

Zuntz:      Vcrhandl.   d.    physiol.    Gcscllsch.,    Rerlin,    1895,   5,  vol.    vii. 

Levene:     Jour.   Physiol.,   1894,   vol.   xvii,  p.   259. 

Coolcn:      Centralb.   f.   d.    Krankh.   d.   Harn-   Scx.-Org.,    1895,  vol.   vi,   p.    530. 

Pavy:     Jour.    Physiol.,    1896,  vol.   x.x. 

Contejean:      Coinpt.    rend.    Soc.    de   biol.,    1896.   vol.   xlviii,    p.    344. 

Markuse:     Allg.   med.   Centr.-Ztg.,   1896,  No.   49. 

Klemperer:      Verhandl.   d.   Ver.   f.   inn.   Med.,   1896,  vol.   v,  p.    18. 

Lepine:      Semaine   med.,    1895,   p.    383. 

Kolish:      Wien.    klin.    Wchnschr.,    1897,    No.    23. 

Lusk,  G. :     Ztschr.   f.   Riol.,   1898,  vol.  xxxvi,  p.   82. 


BLOOD   SUGAR  189 

phlorizin  diabetes  was  replenished  by  protein  and  fatty  tissues 
of  the  body. 

Phlorizin  glycosuria  is  not  dependent  upon  glycogen  of  the 
liver  or  any  other  part  of  the  body,  nor  upon  the  integrity  of  the 
nervous  mechanism  of  any  organ  except  the  kidneys.  It  is  in- 
teresting to  note  that  phlorizin  does  not  appear  to  have  any  harm- 
ful effects  upon  the  animal  organism:  von  Mering  gave  it  to  a 
human  subject  for  thirty  days  without  damage;  others  have 
given  it  to  animals  for  months  without  trouble.  Schwarz  found 
it  highly  toxic  for  rats  after  epinephrectomy.  Concerning  the 
mechanism  of  phlorizin  in  producing  glycosuria,  Allen77  says  it 
is  suggested  that  so  far  as  present  evidence  goes,  the  idea  of  a 
simple  (active  or  passive)  increase  of  renal  permeability  seems 
less  probable  than  the  other  hypothesis,  that  the  kidney  derives 
its  sugar  from  some  larger  molecule  or  complex.  The  nature 
of  the  hypothetical  substance  is  as  yet  unknown.  The  doctrine  of 
Pavy,  Lepine  and  others,  that  the  excreted  dextrose  is  derived 
from  protein,  "virtual"  sugar,  or  some  other  substance  than 
dextrose  itself,  is  supported  by  the  following  evidence : 

1.  The   analyses  which  claim  to  show  a  greater  quantity  of 
dextrose  in  the  urine  and  the  blood  of  the  renal  vein  than  in 
the  blood  of  the  renal  artery.     (He  refers  here  to  the  fact  that 
Lepine  in  1894  was  the  first  to  claim  that  in  phlorizin  poisoning 
the  blood  of  the  renal  vein  contains  more  dextrose  than  the  ar- 
terial blood.)     His  analyses  of  the  blood  also  showed  a  constant 
decrease  of  the  general  amount  of  proteids  and  a  varied  relation 
between  the  serum  albumin  and  the  serum  globulin.    Serum  albu- 
min is  usually  decreased  in  quantity,  while  serum  globulin  is  in- 
creased. 

2.  The  production  of  glycosuria  after  exclusion  of  viscera,  in- 
volving excretion  of  more  sugar  than  contained  in  the  blood. 

3.  The  experiments  in  which  excised  kidneys  formed  a  seducing 
substance  when  prefused  with  sugar-free  fluid  containing  phlor- 
izin. 

4.  The  calculation  of  Erlandsen,  that  derivation  of  the  urine 
sugar  from  the  blood  sugar  would  involve  complete  sugar  free- 
dom of  the  blood  of  the  renal  vein.     Allen  states  very  properly 


TAllen:     Studies  Concerning  Glycosuria  and  Diabetes,  Harvard  University  Press,  1913. 


190  BLOOD    AND    URINE    CHEMISTRY 

that  the  best  evidence  at  present  seems  to  stand  somewhat  against 
the  view  that  the  gtycosuria  represents  a  simple,  active  or  pas- 
sive, increase  of  renal  permeability  to  the  ordinary  blood  sugar, 
and  in  favor  of  the  general  view  that  the  excreted  sugar  is  derived 
from  some  sort  of  compound  or  complex,  which  might  be  a  large 
molecule,  or  perhaps  an  abnormal  blood  sugar  combination,  in 
which  phlorizin  itself  might  conceivably  be  a  component.  The 
evidence  which  he  alludes  to  might  be  summed  up  as  follows  : 
(1)  The  possible  analogy  with  the  mellituria  produced  by  gly- 
cogen,  dextrin,  etc.  (2)  The  effects  of  diuresis.  All  glycosurias 
known  to  depend  upon  passage  of  blood  sugar  into  the  urine 
are  increased  by  diuresis:  phlorizin  stands  out  in  contrast.  (3) 
The  diminution  of  permeability  of  the  phlorizinized  kidney  for 
levulose,  perhaps  also  for  saccharose  and  other  sugars.  (4)  The 
apparent  lack  of  parallelism  between  hyperglycemia  and  gly- 
cosuria.  The  contrast  in  this  respect  bet\veen  phlorizin  and  sub- 
stances which  are  known  to  increase  renal  permeability.  (5) 
The  D  :N  ratio,  Phlorizin  cannot  be  considered  a  very  power- 
ful agent  of  primary  sugar-production.  Much  of  the  sugar- 
production  may  be  considered  secondary.  The  theory  of  in- 
creased permeability,  therefore,  cannot  be  satisfactorily  ex- 
plained on  the  basis  of  the  ratio  of  the  phlorizin  poisoning  being 
higher  than  in  diabetes.  The  different  ratio  seems  best  ex- 
plainable on  the  supposition  of  some  radically  different  mecha- 
nism. (6)  The  remarkable  quantitative  relations  in  phlorizin  poi- 
soning. The  assumption  of  a  combination,  requiring  more  or 
less  fixed  quantity  of  sugar  for  its  saturation,  readily  explains 
the  fact  that  a  given  dose  of  phlorizin  poisons  only  for  a  given 
dose  of  sugar-forming  substance,  also  Ringer's  observation  that 
sugar  spares  protein  even  when  the  sugar  itself  is  quantitatively 
excreted.  The  idea  of  a  simple  change  of  renal  permeability 
seems  less  suited  to  explain  these  quantitative  relations.  Allen's 
experiments  seem  to  show  by  the  "paradoxical"  law  and  the 
diuretic  action  of  dextrose  to  sharply  distinguish  between  these 
two  fundamentally  different  conditions,  phlorizin  poisoning  and 
diabetes  mellitus.  By  the  "dextrose  paradox"  or  the  "paradox- 
ical law  of  dextrose"  Allen  means  the  remarkable  power  of 


BLOOD   SUGAR  191 

every  nondiabetic  organism  to  utilize  dextrose  in  absolutely  un- 
limited quantity. 

It  is  curious  that  in  a  very  modern  and  recent  publication,78 
a  writer  calls  attention  to  the  fact  that  phlorizin  glycosuria  is 
sometimes  called  "renal  diabetes"  (italics  ours)  just  as  some  of 
the  older  writers  spoke  of  a  condition  which  we  shall  presently 
take  up,  namely,  "renal  diabetes."  But  it  is  our  impression  that 
phlorizin  diabetes  and  renal  diabetes  are  in  no  way  related  and 
should  not  be  confused,  it  is  true  that  in  both  conditions  there 
is  glycosuria  but  no  hyperglycemia,  but  otherwise  there  is  no 
pathology  known  for  either.  We  must  sharply  distinguish  "renal 
diabetes"  from  diabetes  mellitus,  although  we  have  but  little 
pathology  on  which  to  base  the  gross  or  minute  differentiation. 
Foster79  and  Joslin,80  who  have  written  the  most  recent  works  on 
diabetes  mellitus,  both  insist  that  the  future  conception  of  this 
so-called  "renal  diabetic"  state  must  rest  upon  blood  chemical 
analyses.  Foster  offers  the  suggestion  that  these  cases  of  renal 
diabetes  are  really  cases  of  beginning  diabetes  mellitus,  but  we 
must  confess  that  the  blood  data  on  such  cases  does  not  justify 
this  classification.  Our  conception  of  a  true  case  of  diabetes  mel- 
litus is  one  with  definite  hyperglycemia  and  with  possibly  gly- 
cosuria. If,  therefore,  we  meet  with  a  case  that  shows  no  hyper- 
glycemia and  with  definite  increase  over  the  normal  values  of  the 
urine  sugar,  we  must  classify  this  until  further  notice  as  a  case 
of  renal  diabetes.  The  cases  of  renal  diabetes  so-called  that  occur 
during  the  pregnancy  period  are  sufficiently  illuminating  to  bear 
description.  It  is  well  known  that  in  the  pregnant  state  sugar 
may  at  times  be  found  in  the  urine  but  no  increase  of  blood  sugar 
occurs;  besides,  there  are  no  signs  or  symptoms  of  diabetes 
mellitus  and  the  occurrence  and  presence  of  the  sugar  in  the  urine 
in  no  way  seems  to  influence  for  the  bad  the  pregnant  status. 
These  women  after  the  puerperium,  show  no  glycosu^ia,  and 
yet  when  they  become  pregnant  again,  again  show  glycosuria. 
They  are  justly  entitled  to  be  called  renal  diabetics  and  in  no 
sense  "incipient"  cases  of  diabetes  mellitus. 

In  passing,  we  therefore  urge  the  use  of  blood  analytical  chemi- 


TSMonographic   Medicine,   D.    Appleton   £   Co.,   N.   Y.,    1946,   vol.   iii,   p.    7£ 
79Foster:     loc.  cit. 
80Joslin:      loc.   cit. 


192  BLOOD  AND  URINE  CHEMISTRY 

cal  methods  in  seeking  more  light  upon  the  differential  diag- 
nosis of  renal  diabetes  and  diabetes  mellitus.  Joslin,  who  has 
had  a  very  wide  experience  in  handling  and  studying  diabetes 
mellitus,  states  that  "renal  diabetes  rarely  occurs.  The  re- 
sults of  the  demonstration  of  the  percentage  of  sugar  in  the 
blood  of  diabetics,  which  are  now  being  rapidly  accumulated  will 
throw  light  upon  this  question.  Seven  cases  of  my  series  must 
be  more  carefully  studied  with  this  in  mind.  As  yet  I  am  not  in- 
clined to  classify  any  of  these  as  renal  diabetes. "  In  examining 
the  discussion  alluded  to  by  Joslin  we  regret  to  note  that  his 
observation  of  the  blood  sugar  did  not  occur  on  the  same  day  as 
his  observation  of  the  urine  sugar;  manifestly  giving  us  no 
basis  for  watching  the  ratio  of  subsidence.  He  states  that  "the 
urine  was  usually  sugar-free  at  both  the  time  of  the  first  and 
last  blood  tests.  It  will  be  of  interest  to  compare  these  figures 
with  those  observed  with  a  subsequent  series  of  patients.  It  seems 
remarkable  that  so  many  patients  should  become  sugar-free  and 
yet  the  blood  sugar  remain  so  high.  Presumably  this  is  due  to 
the  short  period  of  time  intervening  between  the  first  and  the 
last  blood  test.  It  would  seem  to  indicate  that  rigorous  dietetic 
treatment  should  be  continued  even  for  a  long  period  of  time 
after  the  patient  becomes  sugar-free." 

A  very  interesting  contribution  to  the  literature  of  renal 
diabetes  is  a  recent  article  by  Lewis  and  Mosenthal.81  They  state 
that  in  this  condition  the  blood  sugar  does  not  vary  from  the 
bounds  of  the  normal,  an  increase  or  decrease  in  the  carbohydrate 
diet  has  little  effect  on  the  percentage  of  sugar  in  the  blood  or  the 
quantity  excreted  in  the  urine.  These  cases  have  none  of  the 
clinical  manifestions  of  diabetes  mellitus,  due  either  to  diminished 
ability  of  the  body  to  utilize  glucose  or  the  presence  of  a  hyper- 
glycemia;  there  is  no  polydipsia,  polyphagia,  or  polyuria,  no 
loss  of  weight  or  weakness,  no  pruritus  or  furunculosis,  or  any 
other  symptom  of  this  disease.  It  remains  stationary,  the  gly- 
cosuria  shows  no  tendency  to  increase,  neither  does  diabetes  mellitus 
develop  from  it;  the  subject. continues  in  good  health  and  without 
any  abnormal  symptoms  except  a  constant  low  grade  glycosuria. 

"Lewis  and  Most-ntlial:     Hull.  Johns  Hopkins  TTosp.,   1916,  vol.   xxvii,   No.   303,  p.    133. 


BLOOD   SUGAR  193 

The  data  necessary  for  the  diagnosis  of  renal  diabetes  are  very 
few  in  number,  but  sharply  defined : 

1.  A  glycosuria,    maintained    at    a    fairly    constant    level    and 
not  markedly  affected  by  changes  in  the  carbohydrate  content  of 
the  food.     , 

2.  A  normal  percentage  of  blood  sugar  while    the    urine    con- 
tains glucose. 

Cases  in  the  literature  are  not  very  common.  Von  Noorden 
was  somewhat  skeptical,  but  Allen82  admits  two  cases,  those  of 
Bonniger  and  Tachau,  as  absolute  examples  of  the  condition. 
Other  cases  are  those  by  Graham83  and  de  Langen.84  Lewis  and 
Mosenthal's  case  report  is  another  undoubted  case  added  to  the 
literature.  The  full  history  of  this  interesting  case  is  as  follows: 

IF.  P.  W.,  Medical  History  No.  34774,  male,  white,  age  29,  born  in  the  U.  S., 
a  station  agent,  descended  from  Anglo-Saxon  ancestry. 

Family  History. — :Father  (aged  60),  mother  (aged  50),  one  brother  and  four 
sisters  are  all  alive  and  in  good  health ;  one  sister  died  of  erysipelas.  With  the 
exception  of  marked  obesity  in  one  grandmother  and  several  of  her  sisters,  there 
is  no  history  of  hereditary  disease ;  diabetes  mellitus,  heart  trouble,  kidney  dis- 
ease, apoplexy,  gout,  exophthalmic  goiter,  and  tuberculosis  have  never  been 
found  in  the  patient 's  family. 

Habits. — Smokes  five  to  six  pipes  a  day;  does  not  use  alcohol;  eats  a  con- 
siderable amount  of  bread  but  no  excess  of  sweets. 

Past  History. — Measles  and  whooping  cough  in  childhood,  malaria  18  years 
ago,  pneumonia  17  years  ago,  varicella,  complicated  by  otitis  media  on  the 
right  side,  15  years  ago.  Venereal  infection  is  denied. 

Present  History.— Three  years  ago  passed  a  life  insurance  examination. 
This  is  the  only  urinary  test  remembered,  until  six  weeks  ago,  when  the 
patient  applied  to  his  physician  for  relief  from  backache.  At  that  time  a 
glycosuria  was  demonstrated.  The  backache  cleared  up  shortly;  the  glyco- 
suria persisted  in  spite  qf  a  restriction  of  the  carbohydrates  in  food.  There 
never  have  been  any  other  symptoms  pointing  to  diabetes  mellitus  with  the 
exception  of  transient  paresthesia  of  the  fingers  (no  loss  of  weight  or 
strength,  no  polyuria,  polyphagia,  no  skin  involvement — pruritus,  furunculosis 
or  other  condition — no  muscular  cramps,  no  pains  in  the  extremities)  ;  there 
have  been  no  evidences  of  pancreatic  disease  (no  pain  in  the  epigastrium,  no 
fatty  diarrhea) ;  all  indications  of  exophthalmic  goiter  have  been  completely 
lacking  at  all  times  (no  exophthalmos,  no  thyroid  enlargement,  no  vomiting, 
nervousness,  cardiac  palpitation,  or  diarrhea) ;  there  have  been  no  signs  of 
acromegaly  or  giantism  pointing  to  a  hypophyseal  involvement;  there  has 
been  no  history  of  a  renal  lesion  (no  headache,  visual  disturbance,  dyspnea, 


s=A11en:     Glycosuria  and  Diabetes,  Boston,    1913. 

S3Graham:      Jour.    Fhysiol.,    1915,   vol.    xlix,    p.    46    (proceedings). 

wde  Langen:     Berl.  klin.  Wchnschr.,   1914,  vol.   li,  p.   1792. 


394  BLOOD    AND    URINE    CHEMISTRY 

vertigo,  edema  or  albuminuria) ;  there  has  never  been  any  skin  pigmentation 
to  suggest  a  cirrhosis  of  the  pancreas  and  liver,  that  is  hemachromatosis. 

For  the  last  two  or  three  years  there  has  been  a  tendency  to  increased 
frequency  of  urination  during  the  day  but  not  at  night.  The  quantities 
voided  have  apparently  not  exceeded  normal.  This  is  evidently  a  pollakiuria 
rather  than  a  polyuria,  which  is  borne  out  by  the  ward  observations  which 
will  be  detailed  further  on. 

There  has  been  a  slight  chronic  cough  associated  with  a  moderate  nasal 
catarrh,  and  mouth  breathing.  There  have  ln>en  no  night  sweats,  hemoptysis, 
or  '  •  pleuritic  pain. ' ' 

Present  Complaint. — The  patient  feels  perfectly  well  and  would  not  be- 
lieve himself  sick  were  it  not  for  the  persistent,  "sugar-in-the-urine. " 

Physical  Examination. — Height  5  feet,  9%  inches,  weight  152  pounds;  ap- 
pears to  be  in  the  best  of  health  and  spirits;  the  skin  and  mucous  membranes 
are  not  pigmented,  their  color  is  normal,  they  are  as  moist  as  those  of  a 
normal  individual.  The  pupils  are  equal  and  react  to  light  and  accommoda- 
tion; Von  Graefe's  sign  is  absent.  The  pharynx  is  injected  and  there  is  a 
moderate  degree  of  nasal  obstruction,  as  indicated  by  persistent  mouth 
breathing.  The  tonsils  are  not  enlarged  or  inflamed.  There  is  no  pyorrhea 
alveolaris.  The  thyroid  is  barely  palpable.  The  pulse  rate  averages  75;  the 
pulse  is  regular  in  force  and  frequency  and  of  normal  value.  The  radial 
artery  can  be  rolled  under  the  palpating  finger,  but  is  soft  and  elastic.  The 
temperature  is  normal.  The  respiratory  rate  ranges  from  16  to  24.  The 
systolic  blood  pressure  is  140,  the  diastolic  80.  The  heart 's  apex  beat  cannot 
be  seen,  it  is  barely  palpable  in  the  fifth  interspace,  10  cm.  to  the  left  of  the 
median  line;  the  character  of  the  apex  impulse  is  a  normal  one;  there  are  no 
thrills  over  the  precordium;  the  area  of  relative  cardiac  dullness  extends  3.5 
cm.  to  the  right  of  the  mid-line  in  the  fourth  space,  and  10.5  cm.  to  the  left 
in  the  fifth;  the  heart  sounds  reveal  no  murmurs,  the  second  sound  over  the 
aortic  area  is  somewhat  intensified  and  is  louder  than  the  pulmonic  second 
sound.  The  lungs  arc  normal  except  for  slight  dullness  and  somewhat  pro- 
longed expiration  in  the  right  supraspinous  fossa,  and  at  times  a  few  dry 
rales,  after  coughing,  over  the  same  area.  The  liver  and  spleen  are  not  pal- 
pable and  there  are  no  areas  of  tenderness  or  increased  resistance  over  the 
abdomen.  The  patellar  reflexes  are  very  active.  There  is  no  edema  of  the  face, 
back  or  extremities.  On  the  left  thigh  there  is  a  small  eczematous  patch  fur- 
rowed by  scratch  marks.  The  superficial  lymph  nodes  are  not  enlarged.  The 
hemoglobin  is  100  per  cent  (Sahli),  the  red  blood  cells  are  4,000,000  and  the 
white  blood  cells  are  8450  per  c.mm.  The  Wasscrmanu  test  is  negative. 
The  urine  on  admission  is  clear,  of  reddish  yellow  color,  specific  gravity  1035, 
acid  in  reaction,  negative  for  albumin,  gives  a  distinct  reaction  for  sugar, 
and  on  microscopic  examination  yields  no  casts  or  red  blood  cells;  the  quali- 
tative tests  for  acetone  and  diacctic  acid  arc  negative;  the  'phthalcin  test 
shows  an  excretion  of  42  per  cent  in  two  hours;  Ambard's  constant  deter- 
mined at  various  times  is  0.07,  0.11,  0.08,  0.10. 

Impression. — The  presence  of  glycosuria  was  well  established.  The  urine 
gave  a  positive  reaction  with  both  the  quantitative  and  qualitative  Fehling- 
Bcncdict  reagent,  yielded  gas  on  fermentation  with  yeast,  and  the  unfer- 
mented  urine  rotated  the  polariscope  to  the  right.  The  nature  of  the  gly- 
cosuria will  be  subsequently  discussed.  There  may  have  been  a  healed  tuber- 


BLOOD   SUGAR  195 

cular  lesion  at  the  right  apex;  impaired  resonance,  slightly  prolonged  expira- 
tion and  inconstant  rales  in  this  region  are  not  pathognomonic  of  a  tubercu- 
lous focus;  it  is  certain  that  in  absence  of  fever,  sputum,  night  sweats,  chills 
and  loss  of  weight  an  active  process  is  not  probable  and  therefore  of  no  sig- 
nificance in  explaining  the  glycosuria.  Of  equally  little  importance  is  the 
nasal  obstruction  and  pharyngitis.  The  kidneys  are  anatomically  intact  as 
far  as  the  physical  and  urinary  signs  are  concerned;  the  functional  tests  of 
these  organs,  however,  reveal  some  impairment  as  shown  by  a  slightly  dimin- 
ished phthalein  excretion  and  an  Ambard's  constant  barely  within  what  h'as 
been  in  our  experience  the  upper  normal  figure.  The  connection  between 
such  a  diminished  kidney  function  and  a  possible  renal  diabetes  is  of  ex- 
treme interest.  The  small  eczematous  patch  in  this  case  could  not  be  re- 
garded as  a  complication  of  diabetes  mellitus,  since  the  hyperglycemia, 
which  is  the  direct  etiological  factor  of  such  a  condition,  was  lacking. 

The  urinary  nitrogen  was  determined  by  the  Kjeldahl  process,  the  am- 
monia according  to  Folin,  ,the  glucose  by  Benedict's  modification  of  Feh- 
ling's  method,  the  acid  bodies  by  Shaffer's  procedure.  The  method  of  Lewis 
and  Benedict  was  used  in  estimating  the  blood  sugar. 

Blood  sugar  determined  by  the  Lewis  and  Benedict  method  was  normal, 
although  urine  showed  glucose.  This  case  must  be  classed  as  one  of  true 
renal  diabetes.  There  was  slightly  diminished  phenolsulphonphthalein  ex-, 
cretion,  the  slight  elevation  of  Ambard's  constant  above  the  normal,  as 
well  as  the  glycosuria,  point  to  a  depressed  kidney  function.  The  absence 
of  any  further  subjective  or  objective  signs,  past  or  present,  leads  to  the 
conclusion  that  a  renal  glycosuria  is  an  interesting  anomaly,  but  of  no  im- 
portance to  the  organism  as  a  whole. 

The  question  of  prognosis  in  this  condition  is  the  most  important  problem 
which  remains  to  be  solved.  It  is  well  known  that  instances  of  true  dia- 
betes may  persist  for  years  without  changing  from  a  mild  to  a  severe  type 
in  spite  of  the  lack  of  any  systematic  efforts  at  dietary  restriction,  thus 
resembling  renal  glycosuria.  It  is  not  certain  that  what  is  termed  renal  dia- 
betes may  not  develop  into  diabetes  mellitus,  especially  since  compara- 
tively little  is  known  of  the  early  stages  of  true  diabetes.  The  number  of 
cases  of  renal  glycosuria  thus  far  observed  has  been  small  and  none  of  them 
has  been  followed  for  a  sufficient  length  of  time  to  ascertain  whether  renal 
diabetes  is  congenital,  and  not  an  acquired  anomaly,  and  whether  it  may 
persist  indefinitely  without  changing  its  characteristics. 

The  intensity  of  renal  glycosuria  should  vary  with  the  degree  of  kidney 
permeability  to  dextrose.  With  a  threshold  only  slightly  depressed,  an 
intermittent  glycosuria  often  of  an  apparently  unexplained  origin  may  be 
present;  with  a  very  marked  depression,  changes  approximating  the  condi- 
tions found  in  phlorizin  poisoning  should  develop.  Intermediary  de- 
grees of  kidney  involvement  should  have  glycosuria  of  corresponding  in- 
tensity. If  the  present  ideas  of  the  relations  of  a  diminished  kidney  thresh- 
old for  sugar  are  true,  all  the  grades  of  intensity  indicated  should  be  dem- 
onstrated in  the  course  of  time. 

Renewed  interest  is  given  this  subject  by  a  very  recent  com- 
munication from  no  less  an  authority  than  Allen.  Allen,  Wis- 


196 


BLOOD    AND   URINE    CHEMISTRY 


hart  and  Smith"  report  that  among  forty  cases  of  supposed  dia- 
betes received  at  U.  S.  Army  General  Hospital  No.  9  at  Lake- 
wood,  N.  J.,  they  observed  three  cases  which  they  designate  as 
"renal  glycosuria."  Owing  to  the  importance  of  these  observa- 
tions, their  communication  is  given  in  its  entirety. 


TABLE  1 


RESULTS  OF  URINE  AND  BLOOD  EXAMINATIONS  AFTER  VARIOUS  DIET 
MODIFICATIONS 


Date 

Diet 

Urine 

Plasma 

Remarks 

Carbo- 
hy-         P™-     Calo- 

Gm?'      G™'      n6S 

Volume, 
c.  c. 

Glucose, 
Gm. 

Nitro- 
prussid 
Test 

Sugar 
Per 
Cent. 

Nov.  2 

125       125       1,100 

960 

Heavy 

Negative 

Diet  poor  in  fat. 

3 

125         75         898 

1,000 

Heavy 

Negative 

4 

125         75         898 

850 

2.4 

Negative 

5 

125     '    75         898 

1,380 

6.76 

Negative 

6 

125         75         898 

856 

10.67 

Negative 

7 

Fast  Day 

1,600 

6.40 

Negative 

8 

Fast  Day 

1,250 

Negative 

Negative 

0.088 

Blood   taken   11    a.m. 

and  3  p.m. 

9 

Regular  Diet 

1,100 

13.09 

Negative 

0.100 

Blood  taken  during  di- 

gestion at  2:30  p.m. 

10 

Regular  Diet 

1,080 

Heavy 

Negative 

11 

Regular  Diet 

975 

Heavy 

Negative 

12 

0       150         801 

1,350 

Heavy 

Faint 

13 

0       150         801 

1,250 

4.63 

Faint 

14 

0       150         801 

1,425 

Heavy 

Faint 

0.098 

Blood  taken  during  di- 

gestion at  2:30  p.m. 

15 

0       150         801 

1,400 

Heavy 

Faint 

16 

0       150         801 

650 

1.50 

Faint 

0.089 

Blood       taken       after 

breakfast;  blood 

urea,    31.7    mg.    per 

100  c.  c. 

17 

0       150         801 

600 

1.90 

Faint 

18 

0       150         801 

400 

3.00 

Faint 

19 

Regular  Diet 

450 

2.8 

Faint 

Phenolsulphonephthal- 

ein    test,     1st    hour 

35%;  2d  hour  18% 

20 

Regular  Diet 

1,350 

23.70 

Negativa 

21 
22 

Regular  Diet 
Regular  Diet 

1,400 
850 

Heavy 

8.1 

Negative 
Negative 

23 

Regular  Diet 

625 

6.4 

Negative 

0.080 

Blood     taken      before 

breakfast 

24 

Regular  Diet 

850 

10.1 

Negative 

25 

Regular  Diet 

700 

9.3 

Negative 

26 
27 

Regular  Diet 
Regular  Diet 

875 
950 

Heavy 
12.7 

Negative 
Negative 

28 

Regular  Diet 

675 

10.5 

Negative 

29 

Regular  Diet 

750 

Heavy 

Negative 

30 
Dec.  1 

Regular  Diet 
0          Unlimited 

1,025 
425 

9.4 
Heavy 

Negative 
Negative 

2 

0          Unlimited 

575 

4.5 

Negative 

3 

0          Unlimited 

650 

4.92 

Negative 

4 

0          Unlimited 

775 

5.65 

Negative 

5 

0          Unlimited 

275 

1.90 

Negative 

Urine  partly  lost. 

6 

0          Unlimited 

575 

6.36 

Negative 

7 

0          Unlimited 

675 

8.47 

Negative 

8 

0          Unlimited 

550 

5.78 

Negative 

9 

0          Unlimited 

500 

3.70 

Negative 

0.136 

Blood  taken  at  3  p.m. 

BLOOD   SUGAR 


197 


"Report  of  Cases. 

"CASE  1.86 — Private,  infantry,  American,  26  years  of  age,  was  admitted 
Nov.  1,  1918. 

"Family  History. — The  father  died  at  the  age  of  78  from  arteriosclerosis 
and  apoplexy.  The  mother  was  drowned  at  the  age  of  65.  Five  brothers  and 
one  sister  are  alive  and  well.  No  inheritable  disease  is  known  to  exist. 


TABLE  1 

RESULTS  OF  URINE  AND  BLOOD  EXAMINATIONS  AFTER  VARIOUS  DIET  MODIFI- 
CATIONS (CONTINUED) 


Diet 

Urine 

Plasma 

Date 

Carbo-    _ 

fay-     tp-ro"     Caio- 

i  Irate,     tem,         T-iea 
Gm.       Gm- 

Volume, 
c.  c. 

Glucose, 
Gm. 

Nitro- 
prussid 
Test 

Sugar, 
Per 
Cent. 

Remarks 

Dec.  10 

Fast  day 

800 

3.05 

Negative 

0.033 

31ood  taken  at  9  a.m 

11 
12 
13 

Fast  day 
0         Unlimited 
0        Unlimited 

1,675 
3,535 
825 

Negative 
16.46 
15.02 

Negative 
Negative 
Faint 

14 
15 

Regular  diet 
Regular  diet 

850 
975 

25.08 
14.93 

Very  faint 
Very  faint 

16 

Regular  diet 

1,425 

Heavy 

Very  faint 

17 

Regular  diet 







18 

Regular  diet 

550 

8.75 

Negative 

19 

Regular  diet 

725 

12.08 

Negative 

20 

Regular  diet 

760 

5.00 

Negative 

From   December   21 
to  January  6  away 

on  leave. 

Jan.      6 

7 

Regular  diet 
Regular  diet 

150 
625 

Heavy 

7.22 

Negative 
Negative 

Urine  partly  lost. 

8 

Regular  diet 

1,200 

16.41 

Negative 

9 

Regular  diet 

1,075 

23.58 

Negative 

10 

Fasting  after 

645 

7.31 

Very  faint 

breakfast 

11 

Fast  day 

625 

2.00 

Very  faint 

12 

Fast  day 

1,325 

2.12 

Very  faint 

13 

Fast  day 

900 

1.80 

Moderate 

14 

Fast  day 

825 

1.65 

Faint 

15 

Fast  day 

1,255 

Negative 

Slight 

16 

0         51.2        357 

1,725 

Moderate 

Slight 

17 

0       138.8        913 

Steak,  250  gm.  diet 

for  day. 

18 

Regular  diet 

750 

8.41 

Moderate 

Meat,  600  gm.  diet 

after  p.m. 

for  day,  one  meal. 

19 

Regular  diet 

655 

9.42 

Negative 

20 
21 

Regular  diet 
0         78.5     2,888 

800 
350 

15.71 
3.85 

Negative 
Negative 

Bacon,  100  gm.,  but- 

ter,   50    gm.,    egg 
yolk,    500   gm.    in 
one  meal   (break- 

fast).    Urine  vol- 

ume incomplete. 

22 

Regular  supper 

475 

11.30 

Negative 

"Personal  History. — Patient  had  measles  in  childhood.  He  denies  venereal 
or  other  diseases.  Occasionally  he  drinks  a  glass  of  beer  or  wine;  uses  tobacco 
moderately.  He  has  a  normal  figure.  He  has  the  average  habits  of  diet.  His 
occupation  in  civil  life  was  shipping  clerk.  He  enlisted  May  8,  1917,  and  sailed 
for  France  August  7.  He  did  full  heavy  duty  without  difficulty.  He  suffered 
somewhat  from  mustard  gas  in  June,  1918,  but  did  not  report  sick.  In  July  he 
received  a  slight  muscle  wound  in  the  left  forearm  from  shrapnel  and  after 

s°Lieut.   L.   G.   Foster  participated  in  the  study  of  Case   1. 


198  BLOOD   AND    URINE    CHEMISTRY 

a  week  in  the  hospital  a  small  fragment  was  removed  surgically.  This  shell 
exploded  about  thirty  feet  away  and  the  patient  received  no  special  shock  or 
fright.  Glycosuria  was  discovered  in  the  routine  examination  at  this  time. 
Symptoms  of  slight  pruritus,  polyuria,  polyphagia,  weakness  and  loss  of  weight 
were  mentioned  in  the  hospital,  but  no  diet  was  prescribed  and  no  such  symp- 
toms have  been  present  before  or  since.  October  16,  he  was  sent  back  to 
America  with  a  diagnosis  of  diabetes  after  complete  surgical  recovery. 

"Physical  Examination. — The  patient  was  a  tall,  well  built,  muscular  young 
man,  with  the  appearance  and  actions  of  perfect  health.  He  was  always  cheer- 
ful and  active;  free  from  nervousness  or  peculiarities.  A  brown  and  tanned 
appearance  of  the  skin  over  a  large  part  of  the  trunk  and  arms  was  due  to 
mustard  gas.  An  irregular  scar  of  healed  shrapnel  wound  was  evident  on 
the  left  forearm.  His  teeth  were  in  poor  repair.  The  tonsils  and  throat  were 
normal.  Some  palpable  cervical  lymph  nodes  were  noted.  The  heart  was  nor- 
mal in  outline  but  irregular  in  rhythm.  A  diagnosis  of  incomplete  heart  block 
find  auricular  fibrillation  was  made  by  the  cardiac  service  and  was  confirmed 
by  electrocardiogram.  The  examination  was  otherwise  negative. 

"Laboratory  Examination. — The  urine  at  admission  was  clear,  amber  in 
color,  acid,  specific  gravity  1.036,  containing  sugar,  but  no  acetone,  albumin  or 
casts,  blood  or  other  abnormalities.  The  Wassermann  was  negative.  The  blood 
corpuscles  numbered  4,700.000;  the  white,  blood  corpuscles  numbered  10,200; 
small  mononuclears,  22  per  cent.;  large  mononuclears,  10  per  cent.;  polymor- 
phonuclear  nentiophils,  63  per  cent.;  eosinophils,  5  per  cent. 

"Treatment  and  Progress. — The  observations  made  during  most  of  the 
patient 's  stay  in  the  hospital  are  contained  in  Tables  1,  2,  3  and  4. 

"1.  Influence  of  Diet. — The  patient  was  kept  partly  on  weighed 
diets  from  the  diabetic  kitchen  and  was  willing  and  faithful  in 
all  respects.  During  the  periods  indicated  by  'regular  diet' 
he  ate  at  the  general  hospital  mess,  and  also  patronized  the  can- 
teen freely,  like  the  other  enlisted  men.  With  the  exception  of 
December  9  and  the  tolerance  tests,  no  special  variations  of  the 
blood  sugar  on  different  diets  were  observed.  The  influence  of 
the  different  components  on  glycosuria  was  observed  as  follows: 

"(a)  Influence  of  Carbohydrate. — On  low  calory  diets  the  gly- 
cosuria was  apparently  higher  with  carbohydrate  included  (Table 
1,  November  3,  4,  5  and  6)  than  with  it  excluded  (Table  1,  No- 
vember 12  to  November  18).  With  unlimited  calories  there  was 
less  glycosuria  on  carbohydrate-free  diet  (Table  1,  December  1  to 
December  9)  than  during  the  various  periods  of  mixed  diet. 
An  exception  is  seen  in  the  high  excretion  on  carbohydrate-free 
diet  (Table  1,  December  12  and  13)  following  fasting.  The  toler- 
ance tests  (Table  2)  show  the  production  or  increase  of  glycosuria 
by  glucose  feeding. 

"  (b)  Influence  of  Protein. — Table  3  shows  the  production  of 
glycosuria  and  on  January  17  of  hyperglycemia  by  eating  beef- 
steak, but  the  effect  is  far  less  than  that  of  preformed  carbohy- 


BLOOD   SUGAR 


199 


drale.  The"  after  effect  of  different  diets  also  seems  significant. 
After  a  period  of  restriction  to  125  gin.  each  of  carbohydrate 
and  protein,  glycosuria  ceased  with  two  days  of  fasting  (No- 
vember 7  and  8).  After  a  carbohydrate-free  period  in  which 
protein  was  eaten  in  large  quantity,  glycosuria  also  ceased  with 
two  fast  days  (December  10  and  11).  After  mixed  diet  with 

TABLE  2 
RESULTS  OF  GLUCOSE  TOLERANCE  TESTS 


Date 

Time 

Urine 

Plasma 
Sugar, 
Per 
Cent. 

Remarks 

Volume,!      Sugar, 
c.  c.      |        Gm. 

Dec.  12 

9:30  a.m. 

500 

Negative 

0.09 

Taken  after  fasting  2  days 
Drank  200  c.c.  water. 

10:30  a.m. 

205 

Negative 

Drank  200  c.c.  water 

11:30  a.m. 

335 

Negative 

"b.io" 

Drank  200  c.c.  water. 

12:30  p.m. 

300 

Negative 

0.10 

Given   100  gm.  glucose  in  200   c.c. 

water. 

1:30  p.m. 

160 

0.88 

0.214 

Drank  200  c.c.  water. 

2:30  p.m 

370 

6.66 

0.320 

Drank  200  c.c.  water. 

3:30  p.m 

535 

4.82 

0.200 

Drank  200  c.c.  water. 

4:30  p.m 

260 

2.34 

0.170 

Drank  200  c.c.  water. 

5:30  p.m 

125 

0.66 

6:30  p.m 

170 

Faint 

0.130 

Drank  200  c.c.  water. 

7:30  p.m 

40 

Negative 

—  . 

Drank  200  c.c.  water. 

8:30  p.m 
9:00  p.m. 

90 

Negative 

0.090 

Ate  all  the  bacon  and  eggs  he  could. 

10  p.m.  to  4  a.  m. 

"'406'  ' 

Y.04 

Taken  after  3  days  of  regular  diet 

Des.  17 

9:30  a.m. 

92 

0.89 

0.100 

Given   100  gm.  glucose  in  200   c.c. 

water. 

10:30  a.m. 

74 

2.36 

0.106 

Drank  200  c.c.  water. 

11:30  a.m. 

65 

1.76 

0.080 

Drank  200  c.c.  water. 

12:30  p.m. 

65 

0.27 

0.070 

Drank  200  c.c.  water. 

2:30  p.m. 

150 

0 

0.079 

Drank  200  c.c.  water. 

5:30  p.m. 

0.090 

Taken  5  days  after  fasting  and 

Jan.    18 

9:30  a.m. 

200 

0.90 

0.088 

2  days  on  carbohydrate-free  diet. 
Given   100  gm.  glucose  in  200   c.c. 

water. 

10:00  a.m. 





0.167 

Drank  200  c.c.  water. 

10:30  a.m. 

300 

3.00 

0.214 

Drank  200  c.c.  water. 

11:30  a.m. 

200 

9.00 

0.185 

Drank  200  c.  c.  water. 

12:30  p.m. 

300 

4.29 

0.136 

Drank  200  c.c.  water. 

1:30  p.m. 

255 

1.15 

0.116 

Drank  200  c.c.  water. 

2:30  p.m. 

150 

0.44 

0.088 

Taken  after  2  weeks  of  regular  diet 

Feb.     3 

9:30  a.m. 

105 

Moderate 

0.107 

Given  100   gm.   glucose   in  200   c.c. 

water. 

10:00  a.m. 

150 

Moderate 

0.133 

10:30  a.m. 

25 

Heavy 

0.142     . 

11:30  a.m. 

None 

0.158 

12:30  p.m. 

50 

Heavy 

0.101 

1:30  p.m. 

35 

Heavy 

0.086 

5:00  p.m. 

80 

Moderate 

0.115 

* 

unlimited  carbohydrate,  five  days  of  fasting  was  necessary  before 
sugar  freedom  was  attained  January  15.  Hypothetically,  the 
smaller  immediate  effect  of  protein  is  explainable  on  the  assump- 
tion that  not  all  the  carbohydrate  theoretically  derivable  from 
it  is  necessarily  formed  from  it  in  metabolism,  and  the  smaller 


200 


BLOOD    AND    URINE    CHEMISTRY 


TABLE  3 
RESULTS  OF  PROTEIN  TESTS 


Urine 

Plasma 

Date 

Time 

Volume, 

Sugar, 
Qualita- 

Sugar, 
Per 

Remarks 

c.  c. 

tive 

Cent. 

Test 

Jan.    16 

9:35  a.m. 

200 

Faint 

0.100 

Two  bloods  fasting  and  urines   for 

10:45  a.m. 

106 

Negative 

0.102 

the  period.     At  12  noon  fed  pro- 

12:00 noon 
12:55  p.m. 

32 

38 

Negative 
Slight 

0.097 

tein  meal,  250  gm.  steak. 

1:35  p.m. 

325 

Slight 

0.115 

2:35  p.m. 

175 

Slight 

0.107 

3:35  p.m. 

250 

Negati  ve 

0.122 

Jan.    17 

5:00  p.m. 
8:30  a.m. 

150 
96 

Negative 
Faint 

0.075 
0.094 

Two   bloods   fasting  and  urines  for 

9:30  a.m. 

40 

Faint 

0.113 

the  period.     At  10:20  a.m.  fed  pro- 

10:20 a.m. 

40 

Faint 

0.106 

tein  meal,  600  gm.  steak. 

11:20  a.m. 

40 

Faint 

0.114 

12:30  p.m. 

90 

Slight 

1:30  p.m. 

96 

Slight 

0.140 

2:30  p.m. 

135 

Slight 

— 

3:30  p.m. 

85 

Slight 

0.129 

4:30  p.m. 

90 

Slight 

— 

5:30  p.m. 

100 

Slight 

0.124 

7:30  p.m. 

95 

Slight 



8:30  p.m. 

— 

0.109 

TABLE  4 

RESULTS  OF  FAT  FEEDING  EXPERIMENT* 


J 

anuary  2 

I 

8:45  a.m. 

12:30p.m. 

3:30  p.m. 

Remarks 

Plasma  sugar,  per  cent  

0.105 

0.100 

0.100 

9  p.m.  Finished  larg;- 

Corpuscle  sugar,  per  cent  

57.8 

48.5 

46.0 

fat   meal  consisting 

Qualitative  lipemia  

Negative 

Faint 

Slight  + 

of  bacon,   100  gm.; 

Total  fat: 

butter,  50  gm.;    egg 

Whole  blood,  per  cent  

0.62 

0.78 

0.7!) 

yolks,     500      gm. 

Plasma,  per  cent  

0.84 

0.90 

0.84 

Urine     up     to      10 

Corpuscles,  per  cent  

0.08 

O.G7 

0.74 

p.m.;     volume    350 

Total  fatty  acid: 

c.c.;  sugar  385  gm. 

Whole  blood,  per  cent  

0.51 

0.54 

0.52 

Plasma,  per  cent  

0.51) 

0.64 

0.60 

Corpuscles,  per  cent  

0.40 

0.43 

0.44 

Cholesterol: 

Whole  blood,  per  cent  

0.24 

0.25 

0.25 

Plasma,  per  cent  

0.25 

0.26 

0.24 

Corpuscles,  per  cent  

0.22 

0.24 

0.26 

Lecithin: 

Whole  blood,  per  cent  

0.48 

0.45 

0.45 

Plasma,  per  cent 

0  .  45 

0.45 

0.43 

Corpuscles,  per  cent  

0.50 

0.45 

0.48 

*  Total   fat,   cholesterol   and   lecithin   are   determined  directly.      Total  fatty  acid   =  fat  — 
cholesterol  (Bloor) . 


BLOOD    SUGAR  201 

after  effect  by  the  well-known  fact  of  the  smaller  glycogen 
storage  from  protein  as  compared  with  carbohydrate.  The  ob- 
servation is  interesting  as  indicating  that  stored  material  affects 
the  glycosuria. 

"  (c)  Influence  of  Fat  and  Total  Calories. — No  experiments  with 
pure  fat  or  alcohol  ingestion  were  performed.  The  disappear- 
ance of  glycosuria  on  fasting  is  more  probably  explained  by  the 
simple  withdrawal  of  carbohydrate  than  by  a  fall  in  total 
metabolism.  In  comparing  differing  diets  it  is  seen  that  the 
glycosuria  in  the  low  calory  period  (Table  1,  November  3,  4,  5 
and  6)  is  fully  as  high  as  could  be  expected  in  comparison  with 
the  periods  of  unrestricted  diet,  considering  the  much  larger 
carbohydrate  intake  in  the  latter ;  and  on  carbohydrate-free  diets 
the  glycosuria  in  the  low  calory  period  (Table  1,  November  12 
to  November  18)  compares  well  with  that  in  the  high  calory 
period  (Table  1,  December  1  to  December  9),  considering  the 
larger  quantities  of  protein  eaten  in  the  latter.  Therefore,  as 
far  as  the  observations  permit  judgment,  there  is  no  indication  of 
an  influence  of  the  total  caloric  ration,  aside  from  the  portion 
represented  by  the  direct  carbohydrate  forming  foods. 

"2.  Plasma  Sugar. — This  was  determined  by  the  Benedict 
method,  and  was  regularly  below  or  near  0.1  per  cent.  Fractional 
urine  specimens  were  taken  so  often  as  to  leave  no  doubt  that  gly- 
cosuria actually  occurred  at  this  level.  Protein  ingestion  or  carbo- 
hydrate-free diet  seemed  to  create  a  tendency  to  hyperglycemia. 
The  single  high  blood  sugar  of  Table  1,  December  9,  occurred  on 
carbohydrate-free  diet.  Other  observations  are  mentioned  in  the 
two  following  paragraphs. 

"3.  Glucose  Tolerance  (Table  2).— The  patient  took  100  gm. 
glucose  on  an  empty  stomach  on  occasions  when  the  diets  of  the 
preceding  days  had  been  different.  December  17,  after  three 
days  of  ordinary  mixed  diet,  there  was  no  rise,  but  instead  a 
slight  fall  in  the  plasma  sugar.  February  3,  after  two  weeks  of 
mixed  diet,  the  curve  rose  to  about  a  normal  height,  but  was 
atypical  in  that  the  peak  came  at  the  end  of  two  hours.  Decem- 
ber 12,  after  fasting,  the  behavior  was  radically  different  and 
the  hyperglycemia  reached  0.320  per  cent.  January  18,  after 
carbohydrate-free  diet,  there  was  again  hyperglycemia,  but  to  a 


202  BLOOD    AND   URINE    CHEMISTRY 

less  marked  degree.  The  two  curves  first  mentioned  are  uncom- 
mon, but  not  peculiar  to  this  condition.  They  represent  some 
abnormality  in  the  patients  who  show  them,  but  whether  this  per- 
tains to  absorption  or  metabolism  is  not  always  clear.  The  hyper- 
glycemia in  the  two  curves  last  mentioned  is  nothing  extraor- 
dinary. The  increased  tendency  to  hyperglycemia  and  gly- 
cosuria  resulting  from  fasting  is  a  long  familiar  fact,  and  there 
are  a  few  observations  of  a  similar  effect  of  carbohydrate-free 
diet.  No  confusion  should  exist  between  this  and  the  other  fact 
that  fasting  and  carbohydrate-free  diet  are  used  to  increase  the 
carbohydrate  tolerance  in  diabetes.  The  carbohydrate  sensitive- 
ness of  the  normal  fasting  organism  is  a  trivial  phenomenon, 
evidently  expressing  nothing  more  than  some  state  of  temporary 
unpreparedness  for  the  carbohydrate  flood.  The  actual  assimila- 
tion of  carbohydrate  is  limited  only  by  the  dose.  In  diabetes 
carbohydrate  metabolism  is  fundamentally  impaired,  and  is 
strengthened  through  the  rest  afforded  by  carbohydrate-free  diet 
and  still  more  by  fasting. 

"4.  Protein  Ingestion.— On  January  16  (Table  3')  250  gm. 
beefsteak  gave  rise  to  slight  glycosuria  without  hyperglycemia. 
January  17,  600  gm.  steak  caused  a  more  distinct  rise  of  blood 
sugar,  but  the  glycosuria  was  still  too  slight  to  warrant  titration 
by  ordinary  methods.  December  12  and  13  (Table  1)  there  was 
exceptionally  high  glycosuria  with  carbohydrate-free  diet,  pre- 
sumably because  the  patient  either  ate  more  protein  or  was  sen- 
sitized to  it  by  the  preceding  fast. 

"5.  Renal  Threshold. — It  would  have  been  desirable  to  make 
a  more  detailed  study  of  this  point,  but  the  existing  observations 
are  opposed  to  the  idea  that  the  blood  sugar  level  was  the  sole 
factor  determining  either  the  occurrence  or  the  quantity  of 
sugar  excretion.  In  the  tolerance  tests  this  was  evidently  greatest 
when  the  blood  sugar  was  high  (Table  2),  but  was  higher  Janu- 
ary 18  than  December  12,  though  the  hyperglycemia  was  higher 
December  12.  In  Table  3,  it  is  evident  that  the  qualitative  uri- 
nary reactions  do  not  correspond  accurately  to  the  levels  of  blood 
sugar;  also  the  excretion  was  trivial  throughout,  though  the  blood 
sugars  after  these  protein  meals  were  often  higher,  notably  Janu- 


BLOOD   SUGAR  203 

ary  17,  than  during  the  marked  glycosuria  of  the  glucose  tests, 
especially  December  17. 

"6.  Urine  Volume. — On  the  whole,  there  was  oliguria,  some- 
times so  marked  that  the  patient  was  led  to  inquire  about  it  him- 
self. No  indication  was  found  of  any  cause  other  than  a  failure 
to  drink.  Whenever  more  fluid  was  taken  on  instructions  or 
accidentally,  the  twenty-four  hour  urine  increased  in  proportion, 
and  the  body  weight  never  indicated  fluid  retention. 

"7.  Glucose  and  Water  Diuresis.— In  Table  1  no  relation  is 
perceptible  between  the  volume  and  sugar  content  of  the  urine, 
in  the  sense  either  of  polyuria  or  oliguria  caused  by  sugar,  or  a 
flushing  out  of  more  sugar  by  increased  urinary  volume.  In  the 
glucose  tests  (Table  2)  the  water  intake  was  regulated  except 
February  3.  The  two  tests  with  hyperglycemia  showed  the  fol- 
lowing :  December  12  a  fall  in  urine  volume  accompanying  the 
hyperglycemia  and  slight  glycosuria  of  the  first  hour  after  the 
glucose  dose ;  in  the  ensuing  hours  polyuria,  roughly  parallel  to 
the  hyperglycemia,  but  not  to  the  urinary  sugar;  then  marked 
oliguria  after  hyperglycemia  and  glycosuria  had  subsided.  Janu- 
ary 18,  less  hyperglycemia  and  less  polyuria,  though  the  urinary 
sugar  was  greater  than  December  12,  and  a  less  marked  diminu- 
tion of  urine  after  the  blood  sugar  had  fallen.  December  17, 
with  no  hyperglycemia,  but  moderate  glycosuria  (the  percentages 
of  urine  sugar  running  higher  than  December  12)  there  was 
striking  oliguria,  with  a  moderate  increase  in  volume  in  the  2:30 
P.M.  specimen  when  glycosuria  had  ceased,  the  whole  experiment 
being  characterized  by  water  retention  even  exceeding  that  of 
normal  persons.  In  general,  therefore,  the  urine  volume  seemed 
to  be  influenced  by  the  blood  sugar  but  to  be  independent  of  the 
urinary  sugar. 

"8.  Renal  Function  (Table  1).— The  blood  urea  of  31.7  mg. 
per  100  c.c.  November  16  is  a  noticeably  high  figure,  though 
probably  affected  somewhat  by  the  carbohydrate-free  diet.  No- 
vember 19  the  phenolsulphonephthalein  elimination  was  35  per 
cent  in  the  first  hour  and  18  per  cent  in  the  second  hour. 

"9.  Character  of  Sugar  Excreted. — Fresh  urine  samples  were 
taken,  along  with  those  from  patient  No.  2,  to  Dr.  P.  A.  Levene, 
who  prepared  and  identified  glucosazone,  and  excluded  the  pres- 


204  BLOOD   AND    URINE    CHEMISTRY 

cnce  of  disaccharids,  levnlose,  pentoses  and  giycuronic  acid.  In 
this  hospital,  the  routine  reduction  tests  with  Benedict's  solution 
were  sometimes  fairly  normal  in  appearance,  sometimes  slow  and 
atypical.  In  titratioii  with  Benedict's  quantitative  reagent  the 
end  points  were  satisfactory.  Fermentation  with  Fleischmann's 
yeast  was  prompt  and  complete  in  tests  made  at  intervals  through- 
out the  stay  in  hospital,  except  for  one  short  period  when  a  few 
negative  or  incomplete  fermentations  were  obtained.  These  were 
not  thoroughly  controlled,  and  may  therefore  represent  mistakes 
of  some  kind. 

"10.  Blood  Lipoids. — According  to  Bloor,  normal  fasting  blood 
contains,  in  whole  blood,  plasma  and  corpuscles,  respectively,  as 
a  maximum  0.41,  0.43,  0.45  per  cent  fatty  acids;  0.25,  0.31,  0.23 
per  cent  cholesterol,  and  0.33,  0.26,  0.44  per  cent  lecithin. 

"Table  4  shows  that  the  cholesterol  was  normal  in  this  patient, 
not  elevated  as  in  the  more  severe  grades  of  true  diabetes.  It 
did  not  increase  during-  digestion  of  a  meal  rich  in  cholesterol. 
The  lecithin  was  elevated  to  a  degree  comparable  with  many  dia- 
betic cases,  but  failed  to  rise  during  digestion.  The  fasting 
values  for  total  fat  and  fatty  acids  are  normal,  but  the  absence 
of  a  digestive  increase  is  remarkable.  A  slight  turbidity  of  the 
plasma  developed  during  digestion,  but  Bloor  and  Gray  have 
shown  that  this  is  not  a  reliable  index  of  chemical  lipemia. 

"CASK  2. — Lieutenant,  ammunition  transport  service,  American,  married, 
aged  42,  was  admitted  Nov.  1,  1918. 

"Family  History. — Father,  mother  and  one  brother  are  well.  There  was  no 
history  of  inheritable  disease  in  family. 

"Personal  History. — Patient  had  measles,  mumps,  chickenpox,  scarlet  fever 
and  whooping  cough  in  childhood ;  diphtheria  in  1892 ;  no  other  infections,  lie 
had  no  venereal  diseases,  lie  used  no  alcohol,  and  tobacco  only  in  modera- 
tion. He  subsisted  on  an  ordinary  diet.  He  had  been  an  investment  banker 
in  civil  life  and  lived  under  the  best  hygienic  conditions.  He  had  a  nervous 
temperament,  but  never  manifested  it  to  a  marked  degree.  He  was  a  mem- 
ber of  the  National  Guard,  and  served  three  years  in  the  Philippines,  where 
he  sustained  a  Mauser  bullet  wound  of  the  right  leg  in  1900.  This  healed 
uneventfully.  He  resumed  civil  occupation  until  commissioned  a  first  lieu- 
tenant, May  10,  1917,  and  after  doing  full  duty  in  this  country  for  a  year  went 
overseas  in  May,  1918. 

"Present  Ailment. — July  27,  1918,  the  patient  was  bringing  up  several  truck 
loads  of  small  arms  ammunition  to  the  battle  line  at  Chateau  Thierry,  he 
himself  sitting  beside  the  driver  on  one  of  the  trucks.  They  were  located  by 
a  German  aeroplane  and  the  entire  convoy  was  destroyed  by  a  heavy  concen- 
tration of  artillery  fire,  the  patient  and  two  other  badly  wounded  men  being 
the  only  ones  to  escape  alive.  The  high  explosive  shell  which  wrecked  his 


BLOOD   SUGAR  205 

truck  killed  the  driver  and  hurled  the  patient  to  a  considerable  distance.  While 
being  carried  to  a  French  evacuation  hospital  he  was  wounded  with  shrapnel 
and  gassed  with  phosgene.  His  surgical  injuries  included  superficial  wounds 
and  abrasions  of  feet,  hands  and  back,  and  severe  concussion,  especially  of  the 
base  of  the  spine,  on  which  he  apparently  had  landed  when  blown  from  the 
truck.  He  was  unconscious  for  three  days.  Thereafter  his  mind  was  clear, 
with  no  hallucinations  or  loss  of  memory,  but  he  was  weak,  and  suffered  much 
pain,  especially  on  attempted  movements.  He  was  extremely  nervous  and  appre- 
hensive, and  had  extreme  tremor  and  incoordination,  especially  when  nervous, 
the  muscles  of  .speech  being  involved  like  those  of  the  extremities.  This  con- 
dition continued  with  little  improvement,  while  the  patient  was  moved  from 
one  hospital  to  another.  Finally,  he  was  given  careful  examination  at  a  base 
hospital,  where  glycosuria  was  found  and  the  diagnosis  of  traumatic  diabetes 
was  made,  which  was  assumed  as  a  factor  in  his  unfavorable  progress.  After 
confirmation  of  the  diagnosis  by  higher  staff  officers  in  another  hospital,  the 
patient  was  sent  to  America,  Oct.  9,  1918.  Important  in  connection  with  the 
glycosuria  is  the  fact  that  the  urine  was  found  free  from  sugar  when  the 
patient  received  his  commission  and  again  when  he  was  examined  for  overseas 
duty.  Also,  in  civil  life  he  had  been  intimate  with  a  young  physician,  who  for 
incidental  reasons  had  repeatedly  tested  the  urine  and  found  no  sugar  or  other 
abnormalities.  Also  after  the  injury  glycosuria  is  said  to  have  been  absent 
sometimes,  generally  slight,  and  heavy  especially  when  there  was  nervousness. 

Physical  Examination. — The  patient  is  rather  short  and  stout,  5  feet  0 
inches  in  height,  weighing  ordinarily  160  pounds  (now  the  same).  He  has  an 
excellent  color  and  a  generally  healthy  appearance,  except  for  nervous  manifes- 
tations. The  general  examination  is  negative.  The  pupils  are  equal  and 
react  normally  to  light  and  distance.  The  knee  and  other  reflexes  are  exag- 
gerated, the  response  sometimes  being  in  the  form  of  clonus.  The  patient 
can  barely  stand  and  walk  with  the  aid  of  an  attendant  and  a  cane.  The 
stooped  posture,  gross  tremor  of  the  limbs,  and  shuffling  unsteady  gait  are 
much  like  paralysis  agitans.  He  is  emotional  and  excitable  ordinarily,  and 
hesitates  somewhat  in  speech  because  of  difficulty  both  in  finding  and  in  form- 
ing words.  Any  sudden  noise,  such  as  a  fire  gong,  an  automobile  horn,  or 
oven  the  slamming  of  a  door,  throws  him  into  a  panic  of  helplessness  and 
tremor,  in  which  hie  is  powerless  to  control  his  muscles  or  utter  an  intelligible 
word.  Even  more  than  of  the  incoordination  and  nervousness,  he  complains 
of  pain  in  different  parts  of  the  body,  particularly  along  the  spine,  also  of 
headache  and  insomnia.  Orthopedic  examination  showed  tenderness  of  both 
muscles  and  bones  in  the  affected  regions,  but  no  displacements,  atrophies  or 
other  definite  abnormalities. 

"Laboratory  Examination. — The  urine  at  admission  was  of  a  clear  amber 
color,  acid,  specific  gravity,  1.025 ;  containing  a  copper  reducing  substance,  but 
negative  for  albumin,  acetone  and  indican.  The  sediment  showed  microscopi- 
cally a  little  epithelium  and  amorphous  material,  no  casts.  Later  urine  speci- 
mens were  tested  repeatedly  in  the  hospital  and  were  the  same  in  general  char- 
acter. The  blood  Wassermann  was  negative. 

"Treatment  and  Progress. — The  patient  was  admitted  late  in 
the  afternoon  of  October  25,  after  having  taken  a  full  mixed 
diet  up  to  that  time.  He  received  only  soup,  coffee  and  two  bran- 
agar  muffins  for  supper,  and  the  same  for  breakfast  the  next 
morning.  The  moderate  sugar  reaction  present  at  admission 
diminished  to  a  trace,  but  the  copper  reduction  was  slow  and 
atypical.  It  being  suspected  that  the  case  was  not  a  true  dia- 


20G 


BLOOD    AND    URINE    CHEMISTRY 


betes,  the  fasting  program  was  broken  off  by  a  test  meal  at  noon, 
high  in  carbohydrate  (cereal,  milk,  sugar,  egg,  potatoes,  bread, 
butter,  jam).  The  quantities  were  not  measured,  but  the  patient, 
being  hungry,  ate  heartily.  The  analyses  disclosed  the  follow- 
ing findings: 

TABLE  :> 
PLASMA  AND  URIXE  SUGAR  IN  RELATION  TO  EATING 


Time 

Plasma  Sugar, 
Per  Cent. 

Urine 
Sugar 

Before  eating  
One  hour  after  eating  
Three  hours  after  eating  
Five  hours  after  eating  

0.125 
0.145 
0.144 
0.  114 

Trace 
Faint 
Slight 
Faint 

"One  probable  cause  for  the  hyperglycemia  was  a  fire  drill 
in  the  forenoon,  the  acute  panic  and  helplessness  aroused  by  the 
gong  being  followed  by  great  nervousness  during  most  of  the 
day.  Possibly  also  the  preceding  fast  tended  to  increase  the  hy- 
perglycemia following  carbohydrate  ingestion.  The  patient  was 
extremely  desirous  of  visiting  friends  in  New  York,  and  as  the 
indications  were  against  diabetes,  he  was  allowed  to  go  on  a 
short  leave,  in  the  hope  that  his  nervous  condition  might  be  im- 
proved. 

"He  returned  November  1  much  worse  in  his  nervous  con- 
dition from  the  excitement  of  the  city.  On  a  full  mixed  diet, 
moderate  to  heavy  copper  reduction  tests  were  present  in  every 
urine  voiding  of  every  day.  No  blood  samples  were  taken  lill 

TABLE  (t 
PLASMA  AND  URIXE  SUGAR  AS  INFLUENCED  BY  GLUCOSE  INGEST. ox 


Plasma 

Urine 

Cent. 

Volume,  c.c. 

Sugar 

Before  glucose  :  

0.111 

140 

Slight 

One  hour  after  glucose  

0.111 

.'52 

0.2(i  per  cent. 

Two  hours  after  glucose  

0.  105 

57 

Moderate 

Three  hours  after  glucose  

0.084 

32 

Faint 

BLOOD   SUGAR 


207 


the  nervousness  had  abated  somewhat.  Then,  November  5,  the 
plasma  sugar  was  0.111  per  cent  before  breakfast,  and  November 
8  it  was  0.100  per  cent  two  hours  after  a  carbohydrate  rich  break- 
fast. Also,  November  5  a  test  was  made  with  25  gm.  glucose 
in  150  c.c.  solution,  taken  on  an  empty  stomach  in  the  morning. 
"Beginning  November  12,  a  trial  was  made  of  a  low  calory, 
carbohydrate-free  diet  as  follows: 


TABLE  7 
URINARY  FINDINGS  AFTER  Low  CALORY  CARBOHYDRATE  FREE  DIET 


Date 

Diet 

Urine 

Carbo-        Pro-          Calo- 
hydrate        tein            ries 

Volume, 
c.c. 

Sugar, 
Gm. 

Nitroprussid 
Test 

Nov.  12 

0                      80              589 

1,000 

Moderate 

Faint 

13 

0                     150              803 

1,200 

Slight 

Faint 

14 

0                     150              803 

2,250 

Faint 

Faint 

15 

0                     150              803 

1,200 

2.4 

Faint 

10 

0                     150              803 

640 

Heavy 

Slight 

17 

0                     150              803 

650 

1.14 

Faint 

18 

0                     150              803 

610 

0.34 

Slight 

19 

0                     150              803 

400 

0 

Moderate 

20 

Full  mixed  diet,  unweighed 

925 

13.32 

Faint 

21 

Full  mixed  diet,  unweighed 

500 

5.65 

Negative 

22 

Full  mixed  diet,  unweighed 

1,150 

8.1 

Negative 

23 

Full  mixed  diet,  unweighed 

1,225 

6.37 

Negative 

24 

Full  mixed  diet,  unweighed 

1,150 

8.81 

Negative 

25 

Full  mixed  diet,  unweighed 

1,000 

5.17 

Negative 

26 

Full  mixed  diet,  unweighed 

750 

4.1 

Negative 

27 

Full  mixed  diet,  unweighed 

1,300 

3.6 

Negative 

28 

Full  mixed  diet,  unweighed 

975 

4.23 

Negative 

29 

Full  mixed  diet,  unweighed 

1,475 

3.00 

Negative 

30 

Full  mixed  diet,  unweighed 

Incomplete 

0 

Negative 

Dec.      1 

Full  mixed  diet,  unweighed 

1,450 

Heavy 

Negative 

2 
3 

Full  mixed  diet,  unweighed 
Full  mixed  diet,  unweighed 

Incomplete 
600 

Heavy 
Heavy 

Negative 
Negative 

"Two  plasma  sugar  tests  were  taken  during  the  period  of 
carbohydrate-free  diet,  between  9  and  10  A.M.  in  each  instance 
(during  digestion  of  breakfast).  The  result  was  0.078  per  cent 
November  14,  and  0.094  per  cent  November  16.  Sugar  reactions 
were  present  in  the  urine  for  the  periods  represented  by  the 
blood  samples — faint  November  14,  moderate  to  heavy  November 
16.  There  is  thus  some  indication  of  a  renal  threshold.  Through- 
out the  period  of  observation,  the  urine  was  examined  in  at  least 


208  BLOOD   AND   URIXE    CHEMISTRY 

four  divisions  in  every  twenty-four  hours  (according  to  the 
routine  of  the  diabetic  service).  Sugar  was  constantly  present, 
except  on  three  occasions.  One  of  these  was  the  full  day  No- 
vember 19,  after  a  week  of  low  calory  carbohydrate-free  diet ; 
another  was  November  30  on  full  mixed  diet,  the  test  covering 
not.  quite  the  entire  day,  one  period  being  lost.  The  third  time 
sugar  was  absent  was  a  single  specimen  on  another  date,  on  which 
other  specimens  contained  considerable  sugar.  On  a  mixpd  diet 
shortly  before  leaving  the  hospital,  the  plasma  sugar  was  0.096 
per  cent  January  8,  and  0.080  per  cent  January  11. 

"The  urinary  sugar  regularly  showed  certain  peculiarities. 
In  the  qualitative  test  with  Benedict's  copper  reagent,  the  re- 
duction was  unusually  slow  in  coming,  and  then  often  appeared 
much  heavier  than  usual  with  slow  tests.  The  character  of  the 
reduction  was  atypical,  with  a  strong  tendency  to  formation  of 
the  red  or  black  oxids,  so  that  this  patient's  test  could  generally 
be  picked  out  at  a  glance  from  among  the  tubes  of  diabetic 
tests  in  the  same  rack.  Titration  with  Benedict's  quantitative 
reagent  indicated  lower  percentages  than  would  have  been  ex- 
pected from  the  final  appearance  of  the  qualitative  tests,  and  the 
end  point  was  always  indistinct  and  sometimes  impossible  to  find. 
On  account  of  this  difficulty,  and  the  doubtful  nature  of  the  sugar, 
attempts  at  quantitative  estimation  were  frequently  omitted. 
Many  fermentation  tests  were  carried  out  with  Fleischmann's 
yeast,  with  the  invariable  result  of  no  gas  formation,  or  only 
traces,  and  little  or  no  change  in  the  reducing  properties,  whereas 
glucose  added  to  the  same  urine  fermented  promptly  and  ap- 
parently completely.  As  far  as  could  be  observed,  these  pecu- 
liarities remained  the  same  on  either  a  mixed  or  carbohydrate- 
free  diet. 

"Urine  samples  preserved  with  toluene,  less  than  twenty-four 
hours  old,  were  taken  to  Dr.  P.  A.  Levene,  being  out  of  the  ice- 
box only  for  about  three  hours  on  the  trip  from  Lakewood  to 
New  York.  lie  immediately  observed  the  slow  atypical  reduc- 
tion with  Fehling's  solution,  and  also  performed  tests  which 
excluded  the  presence  of  pentoses,  disaccharids,  levulose  and 
gh'curonic  acid.  Circumstances  then  brought  it  about  that  the 
urine  remained  several  weeks  in  the  ice-box  before  further  test- 


BLOOD   SUGAR  209 

ing.  Dr.  Levene  then  performed  osazone  tests,  and  identified 
glucosazone  by  its  crystals  and  melting  point. 

Other  urine  samples  were  similarly  taken  to  Dr.  Stanley  R. 
Benedict,  who  found  the  sugar  fermentable  with  yeast,  and  ob- 
tained a  comparison  of  titration  and  polarimetric  readings  ap- 
proximating the  theoretical  for  glucose.  He  also  prepared  and 
identified  glucosazone.  (For  other  findings,  see  below.) 

"The  patient's  urine  record  in  Prance  was  never  obtained,  but 
he  stated  that  the  reduction  tests  had  frequently  been  negative 
there,  and  appeared  or  increased  markedly  with  nervous  at- 
tacks. His  nervous  and  general  condition  rapidly  improved  in 
Lakewood  with  the  aid  of  rest  and  physicotherapy,  but  the  re- 
ducing properties  of  the  urine  persisted  unchanged.  When  his 
recovery  was  almost  complete,  he  was  granted  a  thirty  days' 
leave,  which  he  spent  at  rest  and  quiet  recreation  in  the  coun- 
try. He  returned  to  the  hospital  free  from  all  symptoms,  except 
a  slight  nervousness  of  manner,  and  on  his  request  he  was  dis- 
charged Jan.  22,  1919,  to  undertake  quartermaster  duty  in  New 
York.  Notwithstanding  the  other  improvement,  the  reduction 
test  was  positive  in  every  specimen  of  urine  the  same  as  before. 

"Under  the  strain  of  work  and  excitement  the  patient  broke 
down  nervously,  and  was  admitted  to-  another  military  hospital. 
He  improved  more  rapidly  than  before,  was  discharged  from  the 
army  with  no  compensation  for  disability,  and  is  now  in  civilian 
employment  in  New  York.  On  advice,  he  reported  several  times 
to  the  laboratory  of  Dr.  Benedict,  who,  with  'the  fresh  urine, 
fourftl  fermentation  tests  negative  or  very  incomplete,  and  other 
tests  indicating  a  substance  other  than  glucose.  The  problem  of 
identification  may  be  pursued  further  by  Dr.  Benedict,  if  cir- 
cumstances permit. 

"CASE  3. — The  wife  of  an  army  officer,  American,  aged  43  years,  was  ad- 
mitted March  12,  1919. 

' '  Family  History. — Her  father  died  at  63  years  of  age  from  perforated  gas- 
tric ulcer.  Her  mother  is  alive,  but  an  invalid  with  rheumatism.  One  sister 
died  when  18  months  of  age  of  unknown  cause.  One  brother  and  three  sisters 
are  alive  and  well,  though  one  of  the  sisters  is  obese.  No  inheritable  disease 
is  known  in  the  family. 

"Personal  History. — The  patient  had  whooping  cough,  measles  and  chicken- 
pox  in  childhood,  no  other  illness.  She  had  two  pregnancies,  the  first  a  pre- 
mature birth  with  face  presentation.  There  were  no  postpartum  disturbances. 
She  uses  neither  alcohol  nor  tobacco;  has  no  excesses  in  food  or  sweets,  but 
admits  a  tendency  to  become  obese  recently,  so  that  she  would  like  to  reduce 


210 


BLOOD    AND    URINE    CHEMISTRY 


for  the  sake  of  botli  looks  and  comfort.  She  is  not  constipated.  She  spent 
two  years  in  the  Philippines  when  her  husband  was  in  campaign  there : 
otherwise  she  has  lived  the  usual  army  life  in  this  country  under  good  hygienic 
conditions.  Her  husband  has  been  in  France  for  the  present  war,  and  she 
has  tried  to  be  of  service  and  also  suppress  worry  by  prolonged  heavy  work  in 
relief  organizations. 

"Present  Ailment. — After  the  signing  of  the  armistice,  she  experienced 
marked  continuous  lassitude,  also  slight  pruritus  and  loss  of  weight.  This 
led  to  a  medical  examination,  which  revealed  glycosuria,  a7id  she  came  for 
treatment  because  of  the  diagnosis  of  diabetes  rather  than  on  account  of  any 
distressing  symptoms. 

"Physical  Examination. — She  is  5  feet  9  inches  tall  and  weighs  175  pounds. 
She  has  the  appearance  of  perfect  health  and  slight  overweight.  Her  blood 
pres'sure  is  125  systolic,  and  75  diastolic.  The  examination  was  entirely  nega- 
tive, except  for  her  heart.  The  heart  was  normal  in  size  to  physical  and 
fluoroscopic  examination,  and  its  function  was  apparently  normal,  but  there 
was  a  short  systolic  murmur  in  the  aortic  area,  and  electrocardiograms  were 
interpreted  to  indicate  a  rotation  of  the  organ  to  the  right.  Roentgenograms 
did  not  reveal  any  rotation. 

"Laboratory  Examination. — The  Wassermann  was  negative.  A  blood  count 
was  not  made.  The  urine  was  normal  to  routine  tests,  except  for  sugar. 

"Treatment  and  Progress. — The  patient  was  admitted  011  the 
afternoon  of  March  12,  and  was  immediately  started  on  the  usual 
diabetic  fasting-  program  of  soup,  coffee  and  bran  biscuits.  Sugar 
freedom  was  attained 'March  13,  the  charted  excretion  of  0.83  gm. 
being  only  for  the  fore  part  of  that  day.  When  a  carbohydrate 
tolerance  test  was  attempted  with  green  vegetables,  a  faint  re- 
ducing reaction  promptly  returned  and  increased  as  the  carbo- 
hydrate was  increased.  Table  9  gives  the  general  record. 


TABLE  8 
RKNAI,  FUNCTION  TESTS 


Blood  Urea, 
Mg.  per  100  c.c. 

Phthalein  Test 

First  Hour 
Per  Cent. 

Second   Hour 
Per  Cent, 

.Nov.  Hi  
Nov.  19  

22  .  2 

35 

19 

"General  Discussion. — A  review  of  the  literature  is  omitted, 
because  it  has  been  covered  by  several  recent  authors,  and  also 
because  the  facts  do  not  yet  afford  a  simple  or  harmonious  con- 
ception of  the  condition.  Certain  deductions  in  connection  with 
the  present  group  of  three  cases  suggest  themselves  as  follows: 


BLOOD    SUGAR 


211 


."1.  Incidence. — As  the  most  important  characteristic  of  this 
anomaly  is  the  excretion  of  glucose  or  a  glucoselike  substance 
with  a  normal  or  low  level  of  blood  sugar,  the  introduction  of 
simple  methods  of  blood  sugar  analysis  within  the  past  few  years 
has  permitted  a  more  extensive  and  accurate  investigation  than 
was  possible  before.  The  considerable  number  of  wholly  or  par- 
tially demonstrated  cases  reported  in  this  time  has  established 
firmly  the  existence  of  such  condition,  and  has  also  indicated 


TABLE  9 
THE  URINE  AND  BLOOD  FINDINGS  WITH  VARIOUS  DIETS  IN  CASE  3 


Diet 

Urine 

Plasma 

Date 
1919 

Carbo-     _ 
hy-        Pro-    Calo- 
drate,      *?BB«      ries 
Gm.       (jm- 

Volume 
c.  c. 

Glucose, 
Gm. 

Nitro- 
prussid 
Test 

Sugar, 
Per 
Cent. 

Remarks 

Mar.  12 

Admission 

175 

Heavy 

Moderate 

13 
14 
15 

Broth,  bran,  coffee 
25           8.6        154 
50         12.3        269 

500 
775 
700 

0.83 
Faint 
Slight 

Heavy 
Heavy 
Heavy 

0.100 
0.100 

Fasting  blood  sugar. 
Fasting  blood  sugar. 

16 

75         15.2        387 

355 

1.39 

Heavy 

17 

100         16.9        510 

445 

Moderate 

Moderate 

0.122 

Blood    2    hours    after 

noon  meal. 

18 

7.5        0             30 

450 

Very 

Moderate 

faint 

19 

General    hospital    diet 

875 

7.00 

Heavy 

from  now  on. 

20 

800 

11.58 

Slight 

21 

1,000 

9.20 

Negative 

22 

825 

Heavy 

Negative 

23 

24 

800 
1,025 

Heavy 
Heavy 

Negative 
Negative 

0.107 

Blood    3    hours    after 

breakfast 

25 
26 

1,150 
825 

Heavy 
Heavy 

Negative 
Negative 

0.117 

Blood    3    hours    after 

noon  meal. 

27 
28 

1,250 
375 

Heavy 
Heavy 

Negative 
Negative 

Urine     for     only     one 

period. 

29 
30 

975 

Heavy 

Negative 

0.113 

Blood  \Y2  hours  after 

breakfast. 

that  it  is  not  actually  a  rarity.  The  proportion  of  three  'renal' 
cases  to  thirty-seven  of  true  diabetes  in  this  hospital  is  sur- 
prisingly and  perhaps  exceptionally  high,  but  interesting  in  view 
of  the  random  selection  of  patients,  who  were  simply  those  sol- 
diers in  whom  some  military  officer  happened  to  diagnose  gly- 
cosuria.  The  odds  were  thus  strongly  in  favor  of  true  diabetes, 
because  young  diabetics  ordinarily  show  symptoms  leading  sooner 
or  later  to  the  diagnosis,  while  the  vast  majority  of  enlisted  men 
never  had  a  urine  examination  at  any  time,  and  because  of  the 


212 


BLOOD    AND    TIRINK    CHEMISTRY 


absence  of  symptoms  the  'renal'  eases  could  be  discovered  only 
in  that  small  minority  who  were  subjected  to  urinalysis  for  some 
other  cause.  Doubtless  some  of  the  examples  of  atypical  or 
'harmless'  diabetes  which  formerly  puzzled  clinicians  were  ac- 
tually 'renal'  in  character,  and  the  recognition  of  this  group  will 
reduce  the  number  of  diabetic  cases  in  which  it  is  imagined  that 


TABLE  10 

RESULTS  OF  GLUCOSE  TOLERANCE,  PHENOLSULPHONEPHTHALEIN  AND 

MOSENTHAL  FIXATION  TESTS  IN  CASE  3 


Urine 

Plasma 

Date 

Time 

Volume, 
c.  c. 

Sugar, 
Gm. 

Nitro- 
prussid 
Test 

Per  Cent. 

Remarks 

Mar.  19 

9:30  a.m. 

125 

Negative 

Moderate 

0.113 

Fasting    blood   sugar, 

Given  1C 

3  gm.  glucose 

in  200  c. 

c.  of  water. 

10:30  a.m. 

77 

2.4 

Faint 

0.139 

Drank  200 

c.c.  of  water. 

11:30  a.m. 

143 

3.6 

Nega 

.ive 

0.125 

Drank  200 

c.c.  of  water. 

12:30  p.m. 

675 

2.1 

Negative 

0.115 

Phenolsulphonaphthalein  Test 

Date 

Blood  Urea, 
Mg.  per 
100  c.  c. 

Urea 
Index 

Mar.  24 

First  hour  35.6  per  cent. 

Second  hour  28.2  per  cent. 

Mar.  17 

18.62 

Total  63.8  per  cent. 

Mar.  30 

15.77 

188 

Mosenthal  Fixation  Test 

* 

Urine 

Time 

Volume, 
c.  c. 

Sp. 
Gr. 

NaCl, 
Gm. 

NaCl, 
Per  Cent. 

Remarks 

Mar.  31 

10  a.m. 

190 

1.028 

2.21 

1.16 

Breakfast, 

3  a.m.;  dinner, 

12  noon 

100 

1.030 

1.56 

1.56 

12  noon- 

supper,  5:30 

2.  p.m. 

102 

1.035 

1.3! 

1.36 

p.m. 

4  p.m. 

200 

1.030 

2.8! 

1.44 

6  p.m. 

88 

1.035 

1.3E 

1.54 

8  p.m. 
Night 

112 
380 

1.034 
1.034 

1.50 
4.10 

1.34 
1.08 

1,172 

14.99 

diet  may  be  neglected  with  impunity.  Life  insurance  statistics 
furnish  the  best  evidence  against  the  existence  of  abnormal  gly- 
curesis  in  any  high  percentage  of  the  population,  but  they  are 
imperfect  because  of  the  usual  lack  of  blood  analyses;  the  latter 
may  sometimes  be  necessary  for  this  purpose  in  the  future.  It 
is  of  some  interest  for  comparison  that  no  cases  of  levulose, 
pentose  or  glycuronic  acid  excretion  were  found  in  this  service. 


BLOOD   SUGAR  213 

"2.  Etiology. — A.  General  Physical  Condition. — No  constant  re- 
lation was  discoverable  between  the  urinary  anomaly  and  any- 
thing in  the  physical  examination  of  the  patients.  Patient  No. 
1  had  a  remarkable  cardiac  disturbance,  which  appeared  serious 
in  examination,  but  had  never  caused  subjective  symptoms.  Pa- 
tient No.  3'  had  the  suggestion  of  a  slight  cardiac  rotation,  ac- 
cording to  electrocardiographic  examination.  But  the  heart  and 
circulation  of  patient  No.  2  were  normal,  unless  the  nervous  shock 
was  responsible  for  some  functional  change  not  revealed  by  ex- 
amination. Otherwise  all  three  patients  appeared  to  be  in  very 
good  physical  condition.  Patient  No.  1  had  been  slightly,  and 
patient  No.  2  more  seriously  "exposed  to  mustard  gas,  but  the 
woman,  patient  No.  3,  had  remained  safe  in  this  country. 

"B.  Nervous  System. — Patient  No.  2,  when  first  admitted, 
seemed  to  furnish  something  which  had  been  awaited  with  cu- 
riosity throughout  the  whole  duration  of  the  diabetic  service, 
namely,  a  case  of  diabetes  due  to  war  injury.  There  was  a  history 
of  repeated  urine  examinations  showing  absence  of  glycosuria  up 
to  induction  into  service,  then  a  tremendous  shock  and  trauma, 
followed  by  persistent  sugar  excretion.  But  this,  the  only 
traumatic  case  seen,  turned  out  to  be  of  the  'renal'  type,  and 
it  thus  appears  as  though  this  condition  here  had  been  caused 
by  traumatism  and  nervous  shock.  Such  an  occurrence,  if  posi- 
tive, is  important  as  the  only  known  example  of  definite  causa- 
tion of  this  anomaly  by  this  or  any  other  means,  for  certain  cases 
in  the  literature  seem  to  have  been  congenital,  but  in  the  great 
majority  the  time  and  mode  of  origin  have  been  entirely  un- 
known. Patient  No.  3  in  the  present  series  had  had  some  worry 
and  strain,  but  patient  No.  1  was  a  happy-go-lucky  individual,' 
who  had  suffered  no  shock  or  important  injury,  and  was  the 
reverse  of  neurotic  in  nature.  There  is  no  information  whether 
the  urinary  condition  in  these  two  patients  was  congenital,  or  as 
to  the  time  or  cause  if  it  was  acquired. 

"C.  Kidneys. — The  first  writers  on  this  condition  regarded  it 
as  associated  with  nephritis,  and  thus  seemingly  on  a  par  with 
the  occasional  glycosuria  in  animals  poisoned  with  uranium, 
chromium,  etc.  The  more  recently  reported  cases,  including  the 
great  majority  and  the  ones  most  thoroughly  studied,  have 


214  BLOOD    AND    URINE    CHEMISTRY 

been  independent  of  albuminuria  or  known  renal  lesions,  past  or 
present.  But  the  name  'renal  glycosuria'  still  carries  with  it  the 
assumption  that  the  seat  of  the  anomaly  is  in  the  kidney.  None 
of  the  three  patients  in  this  series  had  albumin,  casts  or  blood 
in  the  urine,  or  gave  any  history  of  nephritis,  unless  the  kidneys 
of  two  of  them  might  have  been  irritated  by  mustard  gas.  The 
blood  urea  was  slightly  elevated  in  patient  No.  1,  normal  m  the 
other  two.  The  index  of  urea  excretion  was  normal  in  all  three, 
and  the  Mosenthal  fixation  test  was  normal  in  the  only  one  (No. 
3)  in  whom  this  test  was  made.  On  the  other  hand,  the  phenol- 
sulphonephthalein  elimination  of  all  three  of  these  patients  was 
slightly  low.  The  phenolsulphonephthalein  tests  were  carried 
out  in  the  general  laboratory  of  the  hospital,  by  the  same  workers 
and  with  the  same  technic  as  all  the  tests  of  this  sort  in  the  hos- 
pital. The  poor  phenolsulphonephthalein  function  of  these  three 
patients  may,  perhaps,  be  only  a  peculiar  coincidence,  but  sug- 
gests the  desirability  of  similar  tests  in  other  cases  of  this  kind. 
It  may  be  worth  while  also  to  call  attention  to  the  entire  lack 
of  necropsies  in  such  cases,  and  the  interest  attaching  to  any  that 
may  be  obtainable,  for  questions  not  only  of  ordinary  renal 
pathology,  but  also  (if  the  glycosuria  continues  to  death)  of  the 
Armanni  or  Ehrlich  vacuolation  and  glycogenic  infiltration  which 
is  a  regular  feature  of  severe  diabetes  and  phloridzin  glycosuria. 
"3.  Prognosis. — In  certain  instances  in  the  literature  the  con- 
tinuance of  'renal  glycosuria'  for  many  years  has  been  proved, 
and  apparently  no  case  has  ever  been  described  in  which  it  is 
known  to  have  ceased.  On  the  other  hand,  it  is  reckoned  as 
harmless,  and  no  known  injury  has  resulted  from  it  in  any  re- 
ported case.  Even  in  the  few  cases  of  greatest  severity  in  the 
literature,  in  which  the  sugar  excretion  has  been  so  great  as  to 
be  comparable  to  true  diabetes  and  to  cause  danger  of  acidosis 
when  carbohydrate  was  restricted,  it  was  only  necessary  for  the 
patient  to  take  a  sufficiently  liberal  carbohydrate  diet  to  be  free 
from  all  disagreeable  symptoms,  except  sometimes  polyuria.  This 
condition  thus  furnishes  interesting  evidence  that  the  weakness 
and  other  disturbances  of  health  in  true  diabetes  are  not  due 
solely  to  the  loss  of  sugar  from  tlie  body.  The  importance  of  a 
clear  distinction  in  definition  between  diabetes  and  glycosuria 


BLOOD   SUGAR  215 

(or  glycuresis — Benedict)  is  also  thus  emphasized.  The  observa- 
tions in  the  present  three  eases  conform  to  the  foregoing  state- 
ments concerning  the  prognosis. 

"4.  Urine  Volume. — As  mentioned,  polyuria  has  characterized 
some  cases  in  the  literature,  particularly  when  the  sugar  output 
was  large.  Inspection  of  the  tables  for  these  three  patients  shows 
that  there  was  never  an  excessive  urinary  volume,  but  some- 
times, on  the  contrary,  a  marked  oliguria.  There  was  never  any 
appreciable  fluid  retention,  and  the  elimination  was  proportionate 
to  the  intake,  the  patients  merely  saying  that  they  had  no  desire 
to  drink.  This  behavior  is  not  altogether  exceptional,  as  the 
sugar  excretion,  on  the  whole,  was  rather  low,  and  it  is  well 
known  that  in  certain  cases  of  true  diabetes  the  urine  volume 
for  some  reason  fails  to  show  the  usual  increase.  In  a  few  glucose 
tolerance  tests,  however,  the  fluid  relations  observed  were  of  some 
interest.  Patient  Xo.  3,  for  example,  receiving  100  gm.  glucose 
March  19.  had  considerable  sugar  percentages  in  the  urine,  but 
the  urine  volume  was  in  inverse  relation,  the  marked  polyuria 
of  675  c.c.  in  the  third  hour  coinciding  with  the  lowest  percentage 
of  reducing  substance.  The  peculiarities  of  diuresis  in  the  toler- 
ance tests  of  patient  No.  1  were  mentioned  in  the  description  of  that 
case.  The  influence  of  hyperglycemia  seemed  to  be  opposite  in 
the  two  cases.  There  might  be  a  chance  of  instructive  com- 
parisons of  the  urine  volume  in  true  diabetes  with  hyperglycemia, 
and  that  in  'renal'  cases  with,  perhaps,  equal  glycuresis  and 
either  elevated  or  normal  blood  sugar,  except  for  our  ignorance 
of  the  mechanism  and  even  of  the  exact  nature  of  the  reducing 
substance  in  the  latter  cases.  The  one  general  conclusion  which 
can  be  drawn  from  all  three  of  the  present  cases  is  that  the 
sugar  excretion  and  the  water  excretion,  on  the  whole,  behave 
as  separate  functions.  Increase  of  sugar  does  not  necessarily 
increase  the  urine  volume,  and  increased  water  elimination  has 
no  appreciable  influence  in  sweeping  out  an  additional  quantity 
of  sugar. 

"5.  Metabolism. — A.  Fat  Metabolism. — On  the  whole,  especially 
in  Patients  No.  1  and  2,  acetonuria  was  conspicuous  by  its  ab- 
sence. It  was  present  sometimes  with  fasting  or  restricted  diet, 
but  only  to  the  extent  of  slight  or  moderate  urinary  reactions; 


216  BLOOD    AND    URINE    CHEMISTRY 

a  positive  nitroprusside  test  in  the  blood  plasma  or  lowering 
of  the  CO,  capacity  was  never  observed,  and  also  no  subjective 
symptoms.  Acetonnria  was  distinctly  more  prompt  and  marked 
in  Patient  No.  3,  but  the  difference  is  readily  explainable  by  her 
slight  obesity.  Differences  of  this  order  are  the  familiar  ex- 
perience with  both  normal  persons  and  patients  with  true  dia- 
betes. In  none  of  the  three  cases  of  this  series  was  there  any 
sign  of  unusual  tendency  to  acidosis,  either  as  a  specific  phenom- 
enon or  in  consequence  of  the  loss  of  sugar. 

"A  few  estimations  of  blood  lipoids  were  performed  in  Case  1 
on  the  chance  of  detecting  any  abnormalities;  but  though  the 
lecithin  values  were  high,  and  the  absence  of  digestive  hyper- 
lipemia  seemed  comparable  with  the  absence  of  hyperglycemia 
after  carbohydrate,  no  general  conclusions  can  be  drawn  from 
this  single  experiment. 

"E.  Protein  Metabolism. — As  already  described  under  Case  1, 
a  meal  of  bacon  and  eggs,  eaten  when  glycosuria  was  absent, 
following  the  glucose  tolerance  test  of  December  12,  brought 
about  the  elimination  of  1  gm.  sugar  during  the  night.  The  ex- 
periments with  beefsteak  on  January  16  and  17  showed  that  pro- 
tein could  give  rise  to  slight  glycuresis  with  or  without  eleva- 
tion of  the  blood  sugar.  It  is  well  known  that  phloridzin  gly- 
cosuria is  increased  by  protein  feeding,  and  the  sugar  excretion 
is  supposedly  independent  of  the  blood  sugar  level.  The  observa- 
tions in  Case  1  suggest  some  resemblance  to  the  phloridzin  proc- 
ess in  this  respect. 

"C.  Carbohydrate  Metabolism. — Certain  salient  features  com- 
mon to  these  three  cases  and  to  most  or  all  of  the  genuine  cases 
in  the  literature  may  be  summarized  as  follows:  (1)  A  tendency 
to  glvcosuria  so  strong  that  sugar  freedom  is  possible  only  with 
stringent  restriction  of  diet  or  actual  fasting,  to  such  a  degree 
that  health  would  be  seriously  impaired  by  attempting  to  keep 
glycosuria  absent,  if,  indeed,  life  were  possible  at  all — the  cases 
in  this  respect  surpassing  true  diabetes,  except  for  very  rare  ex- 
amples of  extreme  severity;  (2)  normal  power  of  actual  carbohy- 
drate utilization,  as  manifested  by  'paradoxical  tolerance';  i.  e., 
though  some  process  in  the  kidney  or  elsewhere  causes  the  waste 
of  a  certain  quantity  of  carbohydrate,  and  this  quantity  may  in- 


BLOOD   SUGAR  217 

crease  with  increased  carbohydrate  ingestion,  yet  the  soundness 
of  the  fundamental  assimilative  function  is  shown  by  the  ready 
utilization  of  the  greater  part  of  every  starch  or  sugar  intake, 
no  matter  how  large;  (3)  though  the  blood  sugar  level  is  sub- 
ject to  some  variations,  the  low  values  found  in  many  cases  even 
after  large  starch  or  sugar  ingestion  stand  in  contrast  not  only 
to  the  conditions  in  diabetes,  but  also  to  the  hyperglycemia  of 
normal  persons  after  such  feeding.  The  supposition  that  the  kid- 
neys here  merely  perform,  more  efficiently  than  in  normal  per- 
sons, the  function  of  keeping  the  blood  sugar  concentration  nor- 
mal, encounters  the  following  difficulties:  First,  the  quantity 
excreted  is  often  so  small  compared  with  the  quantity  ingested 
that  the  suppression  of  hyperglycemia  through  this  drain  alone 
seems  questionable ;  second,  the  sugar  curve  does  not  necessarily 
correspond  to  the  severity  of  the  case  or  the  intensity  of  the  ex- 
cretory process;  the  blood  sugar  may  run  low  when  the  sugar 
loss  is  trivial,  or  higher  when  the  excretion  is  considerable ;  third, 
there  are  other  discrepancies,  such  as  found  in  the  protein  test 
of  Patient  No.  1  on  January  17.  Here  glycosuria  was  slight;  not 
only  did  the  kidneys  fail  to  react  so  as  to  keep  the  blood  sugar 
normal,  but  it  was  actually  higher  than  should  be  expected  in  a 
normal  person  under  the  circumstances. 

"D.  Total  Metabolism. — There  was  some  curiosity  whether  the 
sugar  excretion  was  influenced  only  by. the  carbohydrate  or  by  the 
total  calories  of  the  diet,  but  the  observations  on  this  point  were 
very  incomplete.  No  tests  were  performed  with  feeding  of  pure 
fat  or  alcohol.  The  details  with  various  diets  were  mentioned 
in  the  description  of  Case  1.  Patient  No.  2,  because  of  his  nerv- 
ous condition,  was  never  subjected  to  fasting,  but  on  a  carbo- 
hydrate-free diet  of  150  gm.  protein  and  800  calories  the  gly- 
cosuria fell  to  the  vanishing  point  and  possibly  would  have  re- 
mained absent,  the  liberal  protein  alone  failing  to  maintain  the 
glycosuria.  The  only  information  from  Case  3  is  that  glycosuria 
ceased  very  easily  with  fasting  and  returned  with  the  feed- 
ing of  only  25  gm.  carbohydrate  in  green  vegetables.  It  is  a  safe 
general  conclusion  that  'renal  glycosuria'  is  influenced  chiefly 
by  the  preformed  carbohydrate  and  in  smaller  degree  by  the 
protein  of  the  diet ;  but  the  evidence  in  Case  1  indicates,  as  far  as 


218  BLOOD   AND    URINE    CHEMISTRY 

it  goes,  that  there  is  little  or  no  influence  of  the  total  calories 
apart  from  these  direct  sources  of  carbohydrate. 

Determinations  of  the  respiratory  metabolism  may  offer  some- 
thing of  interest  not  only  in  general,  but  particularly  in  regard 
to  the  carbohydrate  economy.  They  may  show  whether  the  rate 
of  combustion  of  ingested  carbohydrate  is  normal,  and  this  again 
may  throw  some  light  on  the  role  of  mass  action  in  assimilation. 
It  seems  to  be  a  general  law  that  when  the  concentration  of  any 
food  substance  is  increased  in  the  blood,  both  the  combustion 
and  the  storage  of  that  substance  are  increased,  but  there  seem 
to  be  obstacles  to  considering  the  latter  increase  as  caused  by 
the  former  through  simple  mass  action.  Therefore,  the  possible 
demonstration  of  a  rise  of  carbohydrate  metabolism  due  to  car- 
bohydrate ingestion  without  the  usual  rise  of  blood  sugar  may  be 
instructive,  though  there  is  an  additional  possibility  that  occult 
forms  of  carbohydrate  in  the  blood  may  require  consideration  as 
well  as  the  ordinary  sugar. 

"6.  Character  of  the  Substance  Excreted. — For  convenience 
and  brevity,  the  terms  'glycosuria,'  ' glucose'  and  'sugar' 
have  been  used  with  reference  to  the  reducing  substance  in  the 
urine,  but  are  not  intended  for  strict  interpretation.  In  Case 
2  the  absence  of  fermentation  with  yeast  created  suspicion  of 
pentosuria,  which  was  excluded  by  the  tests  of  Drs.  Levene  and 
Benedict.  Subsequently,  Benedict  demonstrated  that  the  reduc- 
ing substance  in  this  state  was  neither  glucose  nor  any  of  the 
sugars  heretofore  reported  in  urine,  but  a  new  substance  of  yet 
unknown  nature.  In  Cases  1  and  3  the  reactions  observed  Avere 
typical  for  glucose,  but  in  a  strict  sense  glucose  excretion  was 
not  positively  demonstrated  in  these  or  in  any  cases  in  the  litera- 
ture. Case  2  may  be  exceptional,  but  the  difficulty  with  fermen- 
tation in  Case  1  on  a  few  occasions  suggests  the  possibility  of 
transitions  or  close  relations  as  respects  the  excreted  substance. 
Absolute  demonstration  of  glycosuria  must  consist  of  two  parts: 
first,  strict  proof  that  the  substance  found  in  analysis  is  glucose ; 
second,  proof  that  this  substance  is  present  in  urine  obtained  as 
fresh  from  the  kidney  as  possible,  and  is  not  the  product  of 
changes  occurring  during  standing  or  manipulation  or  even  in 
the  bladder. 


BLOOD   SUGAR  219 

"7.  Nature  of  the  Condition. — Such  scattering  suggestions  as 
the  observations  offered  concerning  the  seat  or  nature  of  the 
anomaly  are  contained  in  the  above  summary.  The  hypothesis  of 
E.  Frank,  that  the  apparently  normal  blood  sugar  is  due  to  im- 
permeability of  the  corpuscles  and  the  basis  of  glycosuria  is  a 
high  level  of  sugar  in  the  plasma,  is  here  excluded  because  all  the 
analyses  were  performed  upon  plasma.  It  had  been  planned  to 
present  a  series  of  parallel  plasma  and  whole  blood  analyses  to 
show  the  permeability  of  the  corpuscles,  both  for  this  reason  and 
also  as  a  matter  of  possible  interest  in  comparison  with  the  ap- 
parently increased  permeability  of  the  kidneys  for  sugar,  but 
it  was  found  at  the  end  that  the  whole  blood  determinations  had 
been  invalidated  by  a  slight  technical  error.  The  proportion  of 
plasma  and  corpuscles  as  indicated  by  centrifugation  in  a  gradu- 
ated tube  was  followed  as  a  routine  in  the  laboratory;  the  results, 
being  normal,  are  omitted,  but  as  far  as  this  method  is  concerned 
no  connection  was  shown  between  this  form  of  mellituria  and 
the  blood  volume  in  Epstein's  sense.  A  similarity  to  the  phlorid- 
zin  process  is  often  suggested,  but  until  something  definite  is 
learned  concerning  the  actual  mechanism  in  one  or  the  other, 
the  comparison  of  unknown  with  unknown  must  remain  unproved 
and  unprofitable.  It  is  difficult  to  bring  all  cases  in  the  literature 
under  the  same  general  rules,  and  uncertain  whether  they  rep- 
resent merely  degrees  and  variations  of  one  fundamental  con- 
dition (confused  sometimes  with  mild  diabetes,  or  possibly  some- 
times complicated  by  it),  or  whether  further  study  will  reveal  a 
group  of  independent  anomalies.  Benedict's  recent  investiga- 
tion87 includes  one  case  which  must  be  classified  under  the  ex- 
isting nomenclature  as  'alimentary  renal  glycosuria,'  provided 
it  is  not  diabetes.  The  general  information  derived  from  Bene- 
dict's new  methods  is  that  all  urine  contains  traces  of  carbohy- 
drate in  varying  kinds  and  quantities,  and  that  marked  differences 
exist  between  individuals.  The  anomaly  in  question  may  prove  to 
be  only  an  unusual  exaggeration  of  this  normal  process;  it  is 
conceivable  that  all  gradations  may  be  found  between  the  strictest 
normality  and  the  most  extreme  'renal  glycosuria'  with  re- 
gard to  the  excretion  of  fermentable  and  unfermentable  carbo- 


S7Jour.   Biol.    Chem.,   April,    1918, 


220  BLOOD   AND    URINE    CHEMISTRY 

hydrate.  Some  facts,  such  as  the  peculiar  blood  sugar  curves  fol- 
lowing carbohydrate  or  protein  ingestion,  do  not  fit  easily  with 
this  supposition,  but  at  present  it  promises  nevertheless  to  be 
the  most  fruitful  field  for  research. 

"Summary  and  Conclusions. — 1.  The  observation  of  three  of 
these  cases,  as  compared  with  thirty-seven  cases  of  true  diabetes 
in  military  service,  and  the  increasing  number  of  reports  in  the 
literature  as  blood  sugar  analyses  are  more  employed,  indicate 
that  'renal'  glycosuria  is  not  as  rare  as  once  supposed,  and  prob- 
ably is  much  commoner  than  other  anomalies  such  as  pentosuria 
or  levulosuria. 

'"2.  The  etiology,  whether  congenital  or  acquired,  is  unknown 
in  two  of  these  three  cases.  The  history  in  one  case'  is  of  special 
interest,  as  suggesting  that  severe  trauma  was  either  the  primary 
or  at  least  the  exciting  cause. 

"3.  There  was  no  indication  of  nephritis  or  renal  abnormality 
in  any  of  the  three  cases,  except  a  slightly  subnormal  phenol- 
sulphonephthalein  elimination. 

"4.  The  apparent  absence  of  harm  in  all  three  patients  on 
unrestricted  diet  with  continuous  sugar  excretion  agrees  with  Hie 
favorable  prognosis  of  this  condition  according  to  the  literature. 
The  only  disturbance  of  health  is  that  resulting  from  the  severe 
restrictions  of  diet  necessitated  by  any  attempt  to  stop  the  sugar 
excretion.  The  sharp  contrast  with  true  diabetes  in  this  respect 
is  of  theoretical  as  well  as  practical  interest. 

"5.  No  fixed  relations  were  observed  between  the  sugar  in 
blood  and  urine.  The  renal  excretion  does  not  necessarily  serve 
to  maintain  a  low  level  of  blood  sugar.  The  output  is  not  always 
higher  with  high  than  with  low  blood  sugar. 

"6.  No  fixed  relations  were  observed  between  sugar  and  water 
elimination,  in  the  sense  either  of  polyuria  due  to  glycosuria,  or  a 
flushing  out  of  extra  sugar  by  increased  diuresis.  More  detailed 
studies  of  this  and  the  preceding  point  would  be  desirable. 

"7.  The  sugar  excretion  seems  to  be  determined  by  the  supply 
of  available  carbohydrate,  especially  preformed,  but  also  to  less 
degree  by  the  potential  carbohydrate  of  protein.  The  fat  ration 
and  total  metabolism,  which  are  important  in  true  diabetes,  are 
probably  without  influence  here. 


BLOOD   SUGAR  221 

"8.  Analyses  of  blood  fat  in  one  case  showed  abnormalities 
from  which  no  conclusion  can  be  drawn.  No  abnormal  tendency 
to  acidosis  was  observable  in  any  of  the  three  cases. 

"9.  The  excreted  substance  in  one  of  the  three  cases  seemed 
to  be  an  unknown  sugar,  distinguished  from  glucose  by  the  ab- 
sence or  incompleteness  of  fermentation.  This  may  be  the  most 
important  observation  of  the  present  study,  and  suggests  the  de- 
sirability of  closer  examination  of  the  fresh  urine  in  such  cases 
for  accurate  identification  of  the  sugar. 

"10.  The  nature  of  so-called  'renal  glycosuria'  is  not  es- 
tablished. Frank's  hypothesis  of  a  high  plasma  sugar  did  not 
hold  in  these  three  cases.  It  is  not  yet  proved  that  the  abnor- 
mality lies  in  the  kidney,  or  that  it  consists  merely  in  a  lowering 
of  the  normal  threshold  of  sugar  excretion.  It  is  possible  that 
cases  differ  in  kind  as  well  as  degree,  and  that  a  group  of  anom- 
alies have  heretofore  been  included  under  this  name." 

Thus  it  can  be  seen  that  blood  chemical  analyses  in  conjunction 
with  the  urinary  tests  will  throw  some  additional  light  on  these 
cases.  The  matter  has  not  been  cleared  up  by  blood  chemistry, 
yet  blood  chemical  measures  have  yielded  data  which  will  enable 
us  to  be  on  the  lookout  for  such  cases  and  will  permit  of  a  better 
classification. 

Before  passing  further  into  the  question  of  true  diabetes  mel- 
litus,  we  might  say  a  word  regarding  the  so-called  alimentary 
glycosuria.  One  formerly  distinguished  between  a  form  due  to 
the  ingestion  of  starch  and  that  due  to  the  ingestion  of  sugar 
(alimentary  glycosuria  e  saccJiaro).  Naunyn88  attempted  to  dis- 
tinguish an  alimentary  glycosuria,  i.  e.,  one  due  entirely  to  the  in- 
gestion of  carbohydrates,  from  a  case  of  diabetes  mellitus,  by  a 
renal  test  meal.  Referring  to  this  question,  the  Journal  of  the 
American  Medical  Association8*  states  in  part : 

"In  certain  individuals  the  capacity  of  utilizing  glucose  is  sup- 
posed to  be  lowered.  It  may  become  sufficiently  deficient*  in  some 
instances  to  lead  to  so-called  alimentary  glycosuria  following  an 
overindulgence  in  carbohydrate  food.  In  a  healthy  person  it  is 
scarcely  possible  to  produce  glycosuria  by  the  lavish  administra- 
tion of  starchy  food,  since  the  liver  can  apparently  store  up  the 


^Naunyn:     Der  Diabetes  Mellitus,  Wien,   1906. 

S!'Editorial:     Jour.   Am.    Med.   Assn.,    Sept.    2,    1916,   p.    748. 


222  BLOOD    AND    URINE    CHEMISTRY 

excess  of  sugar  as  fast  as  it  is  produced  by  the  digestion  of 
starch  in  the  alimentary  canal  and  absorbed  into  the  portal  cir- 
culation. There  is  a  widespread  belief  that  when  preformed  glu- 
cose is  fed,  however,  the  assimilation  limit  may  be  more  readily 
reached  through  rapid  and  unduly  large  absorption  of  soluble 
carbohydrate.  It  may  become  very  important  to  ascertain  an 
incipient  functional  defect  of  this  sort,  since  it  may  be  the  indi- 
cation of  some  impending  diabetic  defect.  Accordingly  it  has 
been  customary  in  some  clinical  laboratories  to  ascertain  the  'as- 
similation limit'  for  glucose  by  feeding  a  measured  quantity  of 
this  carbohydrate  or  some  other  sugar,  such  as  lactose  (milk 
sugar)  or  levulose  (fruit  sugar),  at  one  time,  and  watching  for 
a  transient  glycosuria  as  a  result.  To  the  examination  of  the 
urine  for  sugar  before  and  after  the  administration  of  the  car- 
bohydrate, the  analysis  of  the  sugar  content  of  the  blood  may 
now  easily  be  added. 

"Success  in  ascertaining  an  abnormal  tolerance  in  a  procedure 
of  the  sort  described  evidently  hinges  on  the  ability  to  postulate 
what  a  normal  functional  capacity  of  a  healthy  individual  in  such 
circumstances  should  be.  Lately  it  has  been  asserted  that  whereas 
the  'assimilation  limit'  is  low  in  diabetes,  it  is  abnormally  high 
in  certain  conditions  involving  a  malfuncton  of  some  of  the  en- 
docrine glands  notably  the  pituitary.  Taylor  and  Ilulton,"0  of  the 
Department  of  Physiological  Chemistry  at  the  University  of  Penn- 
sylvania, recently  remarked  that  by  common  consent,  rather  than 
by  accurate  experimentation,  the  limit  of  assimilation  of  glucose 
on  alimentary  administration  has  been  set  at  from  200  to  250 
gms.  on  the  empty  stomach.  From  this  figure  downward  the  stu- 
dent of  diabetes  applies  the  test ;  from  this  figure  upward  the  stu- 
dent of  the  diseases  of.  the  ductless  glands  applies  the  test.  The 
Philadelphia  investigators  have  made  a  number  of  observations 
on  healthy  medical  students,  to  whom  glucose  was  administered 
in  strong  solution  and  in  whom  blood  sugar  content  was  ascer- 
tained immediately  before  and  three  hours  after  the  sugar  was 
given.  As  a  result  it  is  clear  that  nearly  all  the  subjects  tolerated 
the  ingestion  of  200  gms.  without  exhibition  of  glycosuria.  Of 
nine  subjects  who  ingested  300  gms.,  only  three  displayed  gly- 

""Taylor  and    Ilulton:      Jour.    ISiol.    Clu-ni.,    1916,   vol.    xxv,   p.    17.3. 


'BLOOD  SUGAR  223 

cosuria.  Of  the  six  who  ingested  400  gms.,  only  two  had  gly- 
cosuria. In  five  instances  500  gms.  were  given,  with  the  pro- 
duction of  glycosuria  in  but  one.  Taylor  and  Hulton  regard  500 
gms.  as  the  physical  limit  of  ingestion,  except  in  one  who  has 
trained  to  the  test;  it  is  very  large  in  bulk,  inclines  to  nauseate, 
and  apparently  the  excess  is  not  rapidly  absorbed,  so  that  the 
test  probably  means  no  more  than  does  the  administration  of  400 
gms.,  which  is  usually  tolerated.  Polyuria  occurred  rarely,  and 
there  was  no  relationship  between  the  polyuria  and  glycosuria. 
Intestinal  disturbances  were  not  observed.  It  appears,  by  way 
of  contrast,  that  healthy  persons  cannot  ingest  300  gms.  of 
levulose  without  intestinal  disturbances.  Whether  this  result 
is  inherent  in  such  amounts  of  levulose,  or  is  due  to  some  impurity 
in  the  supposedly  pure  preparation  used,  could  not  be  determined. 
The  further  general  conclusion  was  drawn  that  even  the  larger 
quantities  of  sugar  do  not  markedly  influence  the  sugar  content 
of  the  blood.  In  the  majority  of  healthy  adult  males,  according 
to  Taylor  and  Hulton,  there  is,  apparently,  no  limit  of  assimila- 
tion of  glucose ;  a  glycosuria  does  not  regularly  follow  the  largest 
possible  ingestions  of  pure  glucose. 

"Woodyatt,  Sansum,  and  Wilder91  have  very  properly  pointed 
out  that  the  common  clinical  practice  of  estimating  sugar  toler- 
ance as  the  number  of  grams  of  glucose  which  can  be  given  by 
mouth  all  at  once  and  just  fail  to  cause  glycosuria  will  not 
justify  any  tenable  conclusion  respecting  the  power  to  utilize 
glucose.  They  say: 

"  'When  sugars  are  administered  by  the  stomach,  the  length 
of  time  during  wrhich  they  are  actually  brought  to  the  cells  must 
depend  on  the  motor  power  of  the  stomach  and  of  the  bowel  and 
on  the  rates  at  which  the  sugars  can  be  absorbed;  and  even  when 
they  are  given  subcutaneously  or  by  any  other  route  which  in- 
volves absorption  as  a  prelude  to  their  entering  the  blood,  the 
rates  at  which  they  enter  the  blood  will 'depend  on  the  Vates  at 
which  they  are  absorbed.  By  any  of  these,  but  especially  by  the 
oral  method,  the  actual  rate  of  entry  of  sugar  into  the  blood  and 
tissues  at  large  must  vary  with  a  wide  range  of  physical,  physio- 
logic and  pathologic  conditions  over  which  we  have  no  control ; 

"'Woodyatt,    Sansum,   and   Wilder:      Jour.   Am.    Med.    Assn.,    1915,   vol.    Ixv,   p.   2067. 


224  BLOOD    AND    URINE    CHEMISTRY 

nor  will  it  ever  be  possible  by  such  methods  to  force  sugar  to 
enter  the  blood  any  faster  than  it  can  be  absorbed.  The  rate  of 
sugar  absorption  is  a  self-limited  thing,  for  when  a  certain  con- 
centration of  sugar  is  once  present  in  the  blood,  no  quantity  given 
by  mouth  or  subcutaneously  or  intraperitoneally  can  raise  it 
higher. ' 

"The  fact  that  prolonged  hyperglycemia  did  not  arise  in  Taylor 
and  Hulton's  trials  on  normal  persons  is  in  itself  an  indication 
that  one  could  scarcely  expect  marked  glycosuria  to  manifest 
itself.  It  has  been  found  that  a  man  weighing  70  kgs.,  when 
resting  quietly  in  bed,  may  receive  and  utilize  63  gms.  of  glucose 
by  vein  per  hour  without  glycosuria.  The  normal  tolerance  limit 
for  glucose,  expressed  as  a  velocity,  is  established  at  close  to  0.85 
gm.  of  glucose  per  kilogram  of  body  wrcight  hourly,  which  agrees 
approximately  with  what  Blumcnthal  has  established  by  repeated 
small  intravenous  injections  in  animals.  It  can  easily  be  com- 
puted from  such  statistics  that  if  a  man's  resting  requirements 
were  3,000  calories  per  day,  he  could  thus  receive  double  what 
he  needed,  or  enough  to  cover  the  caloric  expenditure  of  vthe 
same  man  during  the  heavy  physical  exertion.  In  view  of  these 
facts  perhaps  the  supposed  increased  'tolerance'  for  glucose  in 
some  of  the  ductless  gland  disorders  relates  to  a  gastrointestinal 
rather  than  a  metabolic  function." 

The  study  of  diabetes  mellitus  is  attracting  great  attention  at 
the  present  time,  mainly  because  of  the  advent  of  the  Allen  starva- 
tion treatment.  This  is  based  on  the  results  of  exact  animal 
experimentation.  It  is  bearing  the  richest  fruit  in  the  form 
of  excellent  therapeutic  results.  Diabetes  mellitus  is  said  to  be 
rapidly  increasing  in  incidence,  yet  this  may  simply  mean  that 
more  cases  are  discovered  now  that  routine  urine  analyses  are 
being  made.  Joslin  states  that  the  frequency  of  diabetes  in  the 
United  States  is  one  per  cent  of  all  individuals  (they  either  have 
the  disease  or  will  develop  it)  ;  also  that  the  frequency  of  diabetes 
in  a  community  may  be  the  index  of  the  intelligence  of  its  phy- 
sicians. The  routine  examination  of  the  urine  of  every  patient 
should  be  made  the  order  of  the  day,  not  altogether  because  we 
want  to  discover  diabetes,  but  because  we  want  to  know  some- 
thing about  other  conditions.  We  urge  that  the  Benedict  tost 


BLOOD   SUGAR  225 

for  sugar  be  given  the  preference  over  all  other  sugar  tests  of 
urine.  It  is  made  from  a  solution  that  is  stable,  and  besides,  shows 
sugar  at  times  when  Fehling's  test  does  not.  This  has  occurred 
in  our  experience  a  number  of  times.  The  routine  examination 
of  urine  does  not  mean  the  examination  of  the  single  specimen  in 
the  morning  before  breakfast.  It  may  be  surprising  to  some  to 
learn  that  at  this  time  sugar  is  often  absent  from  the  urine  of  a 
diabetic. 

If  one  must  rely  on  urinary  tests  and  not  utilize  the  blood  chemi- 
cal methods,  it  must  be  remembered  that  there  are  individuals 
with  a  lowered  power  of  assimilating  carbohydrates  who  secrete 
glucose  only  for  short  periods  in  the  day,  some  time  after  meals, 
and  then  only  in  small  quantities.  Even  true  diabetics  in  the  mild 
stage  are  often,  even  apart  from  diet,  free  from  glycosuria  for 
some  part  of  the  twenty-four  hours,  especially  in  the  morning 
before  the  first  meal.  Kleeii92  stated  this  well  known  fact  as  fol- 
lows: "The  first  and  most  important  rule  is,  therefore,  never  to 
use  for  a  test  a  single  specimen  of  urine  passed  when  the  pa- 
tient's stomach  is  empty,  before  the  first  meal  of  the  day.  The 
best  means  of  deciding  from  a  single  examination  of  the  urine 
whether  a  person  is  normal  or  not  in  this  respect  is  furnished  by 
a  sample  passed  an  hour  after  the  end  of  the  dinner.  At  this 
time  the  excretion  is  at  its  maximum." 

The  routine  examination  of  blood  chemically  will  some  day  be 
required  in  making  clinical  diagnosis.  To  recommend  this  at  the 
present  time  seems  Utopian,  yet  the  results  of  such  a  study  would 
certainly  repay  one  who  follows  it  out.  The  methods  which  have 
been  described  promise  accuracy  and  ease  of  performance  to  those 
qualified  to  undertake  this  work.  It  is  true  that  the  advantage 
of  the  Allen  treatment  lies  in  the  fact  that  the  dietetic  regime  may 
be  carried  out  without  elaborate  tests  of  blood  and  urine,  yet  a 
far  better  control  of  the  treatment  is  within  our  grasp  if  we 
resort  to  blood  chemical  estimation. 

The  author's  data  on  the  following  two  cases,  blood  and  urine 
of  which  they  carefully  studied,  will  demonstrate  the  discrepancies 
between  the  findings  in  urine  and  blood  of  diabetics.  The  first 
case,  Mrs.  R.,  was  under  observation  twenty-four  days,  during 


°-'Kleen:      Diabetes   Mellitus,   P.    Blakiston's   Son   &   Co.,    1900. 


226  BLOOD    AND    URINE    CHEMISTRY 

which  time  she  was  given  the  Allen  treatment.  This  was  a  young 
woman  of  twenty-three,  with  a  history  of  one  brother  dying  of 
diabetes.  She  had  developed  diabetes  mellitus  one  year  before 
coming  under  our  observation.  During  this  time  she  had  been 
under  various  dietetic  regulations  but  had  not  been  able  to  ac- 
complish much  in  the  way  of  permanently  relieving  herself  of 
diabetic  symptoms  or  of  glycosuria.  She  displayed  some  loss  of 
weight  and  polyuria  and  polydipsia.  At  the  time  of  the  first  ex- 
amination she  showed  0.360%  blood  sugar  and  was  excreting  78 
gms.  of  sugar  in  the  twenty-four  hour  specimen  of  urine.  She 
had  a  carbon  dioxide  combining  power  of  68,  with  a  large  amount 
of  acetone  and  diacetic  acid  in  the  urine.  She  was  watched  one 
week  before  beginning  the  Allen  treatment,  on  general  diet.  Dur- 
ing this  time  she  was  given  1/10  grain  parathyroid  three  times 
daily  for  certain  experimental  purposes.  During  this  week's  ob- 
servation, she  showed  a  marked  increase  in  the  amount  of  sugar 
in  the  urine,  but  the  amount  of  blood  sugar  did  not  materially 
change.  Her  chart  is  shown  on  page  227. 

This  patient  has  been  heard  from  several  times.  She  is  now  tak- 
ing over  2,000  calories  and  sugar  has  reappeared  but  once  in  her 
urine.  Under  one  day's  starvation,  this  quickly  disappeared. 
Since  then  she  has  been  sugar-free.  No  opportunity  has  been  had 
since  to  obtain  her  blood  for  examination.  This  might  be 
termed  a  very  successful  issue  under  the  Allen  treatment. 

The  next  case,  that  of  Mr.  W,  represents  what  might  be  termed 
an  unsuccessful  case.  This  man,  aged  55  years,  married,  dis- 
played nothing  in  his  family  history  to  point  to  diabetes,  no 
obesity,  gout  or  tuberculosis  in  father,  mother,  brothers,  sisters 
or  other  relatives.  He  was  an  occasional  drinker,  moderate  at 
venery,  formerly  did  a  good  deal  of  manual  labor,  sleeps  well. 
Three  and  a  half  years  ago  began  to  lose  weight  and  developed 
polyuria,  gradually  developing  polyphagia  and  polydipsia.  Sugar 
was  first  discovered  in  his  urine  three  years  ago  on  account  of 
having  consulted  his  physician  because  of  his  polyuria  and  loss 
in  weight.  So  far  as  etiological  factors  are  concerned,  he  had 
been  addicted  to  dietary  excesses.  He  gave  a  negative  Wasser- 
mann  and  Hecht-Gradwohl  test  for  syphilis,  had  never  had  any 
trauma,  had  occasional  pains  in  the  region  of  the  pancreas  but 
no  palpable  tumor.  There  was  no  disturbance  in  the  thyroids, 


BLOOD   SUGAR 


227 


no  symptoms  of  gout  (blood  uric  acid  was  normal  in  quantity), 
and  no  hypertension.  His  weight  on  coming  under  observation 
was  101  Ibs.,  height  5  feet  8  inches,  marked  loss  of  strength,  marked 
polyuria,  polyphagia,  pains  over  pancreatic  region,  had  numb- 


CASE   OF   MRS.   "R,"    AGE   23    TEARS 


Date 

Wt. 
Kilos 

Diet 
Calor- 
ies** 

BLOOD 
ANALYSIS 

URINE  ANALYSIS* 

Sugar 
Per 
Cent 

CO2 
Combin- 
ing 
Power  of 
Plasma 

Vol. 
C.  C. 

Sp. 
Gr. 

Sugar 
Grams 

Ace- 
tone 

Dia- 

cetic 
Acid 

Indi- 
can 

***9/19 
9/20 
9/21 
9/22 
9/23 
9/24 
***9/25 
9/26 
9/27 
9/28 
9/29 
9/30 
10/1 
10/2 
10/3 
10/4 
10/5 
10/6 
10/7 
10/8 
10/9 
10/10 
10/11 
10/12 
+10/13 
tflO/30 

53.2 
51.4 
53.0 
52.3 
53.2 

siii 

54.1 
54.0 
53.4 
53.6 
53.0 
52.3 
53.2 
54.1 
55.0 
55.7 
54.4 
54.2 
54.2 
54.4 
54.2 
53.9 
54.3 
54.9 

R 
R 
R 
R 
R 
R 
R 
F.  F. 
A.  T. 
A.  T. 
54 
234 
354 
504 
631 
823 
1131 
1305 
1525 
2023 
1719 
1845 
1883 
1819 
1859 

0.360 

68 

2600 
3160 
2600 
3000 
3200 
3500 
3650 
2200 
650 
800 
950 
1200 
720 
700 
850 
800 
1800 
1400 
1300 
950 
1100 
1400 
1250 
1100 
1200 

1037 
1047 
1040 
1042 
1040 
1042 
1040 
1040 
1020 
1022 
1027 
1024 
1026 
1026 
1026 
1029 
1011 
1010 
1011 
1015 
1014 
1014 
1011 
1016 
1015 
1022 

78 
126.4 
104 
150' 
160 
175 
240.9 
110 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
JNeg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 

++++ 
++++ 
++ 
++ 
+4- 
4-4- 
+4- 
Trace 
++ 
+4- 
++++ 
4-4-4-4- 
4-4-4-4- 
++++ 
4-4- 
+4- 
V.F.T. 
V.F.T. 
Trace 
V.F.T. 

4-4-4-4 
4-4-4-4- 
+++4 
++ 
4-4- 
+4- 
4- 
Trace 
4-4- 
+4- 
+4-4-4- 
++ 
+++4- 
+++4 
++ 
++ 
V.F.T. 
V.F.T. 
Trace 
V.F.T. 

++ 
+ 
+ 
Neg. 
+ 
+ 
+ 
Trace 
Neg. 
Neg. 
Trace 
+ 
++ 
++ 
Trace 
4-4- 
Trace 
Trace 
Neg. 
4-4- 
Trace 
+4- 
+4- 
4-4- 
4- 
Neg. 

6.36 
6.120 

62 

6.120 

52  "  ' 

6.i29 

o.iii 

V.F.T. 
V.F.T. 

Neg. 
Neg. 
Neg. 
Neg. 

Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 

4-  +  4-  4- = Large  amount. 
4-4-= Moderate  amount. 
+ = Small  amount. 
V.F.T. = Very  faint  trace. 
*R=  Regular  mixed  diet. 
F.F.= Fat-free  diet. 
A.T.  =  Starvation. 


***During  above  period  patient  was  given 
1-10  grain  of  parathyroid  three  times  a 
day.  Note  increase  in  urine  sugar. 

t  Patient  left  hospital. 

tfUrine  received  by  mail. 


ness  in  legs,  cramps  in  lower  legs,  had  lost  all  teeth  six  months 
before  (pyorrhea  alveolaris),  bowels  constipated,  had  occasional 
headaches,  coughed  frequently,  examination  of  lungs  disclosed 
evidences  of  beginning  tuberculosis  of  left  lung,  confirmed  micro- 
scopically. A  very  much  emaciated  .man,  with  pale  visible 


228  I5LOOD    AND    URINE    CHEMISTRY 

mucosae,  thyroid  normal,  slight  delay  in  contraction  of  pupils, 
hearing  good,  breath  gave  acetone  odor,  arteries  soft.  Diagnosis: 
Diabetes  mellitus  and  pulmonary  tuberculosis.  His  urine  showed 
97.3  grams  sugar  in  twenty-four  hour  specimen  of  2950  c.c.  His 
blood  showed  0.280%  sugar.  (Sec  chart  on  page  229  for  full  facts 
of  this  study.) 

He  was  under  observation  forty-three  days.  He  was  tried  out 
on  the  Allen  treatment  but  responded  very  poorly.  The  highest 
amount  of  calories  he  could  take  without  producing  glycosuria 
was  1060 — clearly  insufficient  to  maintain  life.  He  was  in  a  state 
of  acidosis  at  the  very  beginning  of  his  observation,  showing  a 
carbon  dioxide  combining  power  of  but  50,  with  marked  amounts 
of  acetone  and  diacetic  acid  in  his  urine.  Every  attempt  was 
made  to  prevent  acidosis  and  to  keep  him  sugar-free  and  at  the 
same  time  give  him  sufficient  nourishment  to  support  life,  but  this 
was  never  successfully  consummated.  He  finally  left  the  hospital 
showing  a  persistent  hyperglycemia,  and  a  trace  of  sugar  under 
1060  calorics  of  food.  He  was  apparently  doing  very  badly  un- 
der the  treatment;  besides,  his  tuberculous  infection  seemed  to 
be  making  fast  inroads  upon  his  general  condition.  This  failure 
of  the  Allen  treatment,  of  course,  occurred  in  a  case  that  was 
both  an  advanced  diabetic  and  a  rapidly  advancing  pulmonary 
tuberculous  subject.  The  tuberculosis  infection  naturally  had 
impoverished  his  system  and  prevented  a  fair  trial  of  the  treat- 
ment. We  narrate  the  case,  however,  as  a  very  good  example 
of  a  study  of  blood  and  urine  in  complicated  diabetes  mellitus. 

We  cannot  leave  the  subject  of  diabetes  mellitus  without  call- 
ing attention  to  the  kidney  changes  in  this  disease,  even  though 
the  present  tendency  is  to  believe  that  diabetes  is  due  to  suffi- 
ciency of  the  internal  secretion  of  the  pancreas.  Fit/9:t  has  re- 
cently emphasized  the  importance  of  this  view  of  diabetes.  Ar- 
manni04  was  the  first  to  show  that  in  diabetes  there  is  an  almost 
specific  injury  to  the  epithelium  of  the  straight  tubules  by  which 
they  lost  their  cytoplasm  and  were  transformed  into  hyaline-like 
vesicles  without  definite  structure.  Ebstein9-"1  confirmed  this  find- 
ing and  described  in  coma  a  typical  massing  together  of  necrotic 

"3Fitz:     Arch.   Int.   Mod.,    1917,   vol.    v,   p.   809. 

"'Armanni:      Quoted   by    Cantani.    Lc    diabete   sue  re   et   son   traitement   clietetitiue,    1876 

"•"Ebstein:     Deutsch.   Arch.   f.   klin.   Med.,   1881,  vol.  xxviii,  p.    143;   Ibid.,    1882,  p.   31. 


BLOOD    SUGAR 


229 


CASE    OF    MR.    "W,"    AGE    55    YEARS 


Date 

Wt. 

Kilos 

Diet 
Calor- 
ies** 

BLOOD  ANALYSIS 

URINE  ANALYSIS* 

Sugar 
Per 
Cent 

C0? 

Combin- 
ing 
Power  of 
Plasma 

Vol. 

c.  c. 

Sp. 
Gr. 

Sugar 
Grams 

Ace- 
tone 

Dia- 
cetic 
Acid 

Indi- 
can 

10/1 
10/2 
10/3 
10/4 
10/5 
10/6 
10/7 
10/8 
10/9 
10/10 
10/11 
10/12 
10/13 
10/14 
10/15 
10/16 
10/17 
10/18 
flO/19 
10/20 
10/21 
10/22 
10/23 
10/24 
10/25 
10/26 
10/27 
10/28 
10/29 
10/30 
10/31 
11/1 
11/2 
11/3 
11/4 
11/5 
11/6 
11/7 
11/8 
11/9 

ttii/io 

ttll/11 
11/12 

'ie'.b' 

46.0 
46.0 
45.5 
45.0 
44.3 
44.6 
44.6 
42.5 
43.9 
42.4 
42.4 
42.2 
43.4 
43.4 
43.9 
43.4 
42.8 
43.4 
43.8 
43.4 
43.4 
43.2 
42.9 
43.6 
43.1 
42.8 
42.6 
42.8 
43.5 
42.9 
43.6 
43.0 
43.1 

43.1 
42.6 

42.7 
43.0 
42.8 
43.4 
Patient 

R 
R 
F.  F. 
A.  T. 
A.  T. 
A.  T. 
A.  T. 
I.  S. 
A.  T. 
A.  T. 
A.  T. 
35 
220 
360 
462 
542 
734 
A.  T. 
195 
140 
370 
478 
602 
A.  T. 
600 
629 
A.  T. 
A.  T. 
354 
472 
609 
866 
1038 
1044 
A.  T. 
751 
A.  T. 
A.  T. 
592 
939 
1058 
1060 
Left 

6.280 

"56 

3100 
2950 
1400 
800 
1400 
800 
950 
1200 
520 
740 
1600 
800 
900 
600 
1100 
950 
1600 
1100 
520 
1000 
650 
300 
750 
600 
850 
1000 
900 
850 
1100 
900 
950 
800 
1200 
870 
1050 
1200 
700 
550 
1200 
750 
1100 
1200 

1036 
1040 
1038 
1018 
1017 
1020 
1015 
1014 
1020 
1017 
1010 
1016 
1015 
1015 
1016 
1015 
1015 
1015 
1016 
1016 
1017 
1023 
1020 
1018 
1020 
1020 
1020 
1018 
1015 
1018 
1022 
1020 
1015 
1018 
1015 
1015 
1016 
1015 
1016 
1020 
1020 
1022 

+ 
+ 
++ 
++ 
+ 
+ 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Trace 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Trace 
V.F.T. 
Trace 
V.F.T. 
Neg. 
Neg. 
Neg. 
Trace 
Trace 

+ 
+ 
++ 
++ 
+ 
+ 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Trace 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Trace 
V.F.T. 
Trace 
V.F.T. 
Neg. 
Neg. 
Neg. 
Trace 
Trace 

Neg. 
+ 
Trace 
Trace 
Trace 
Trace 
Neg. 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 
Neg. 
Neg. 
Trace 
Trace 
Neg. 
Trace 
+ 
Trace 
Trace 
Trace 
Trace 
+ 
Trace 
Trace 
Trace 
Neg. 
Trace 
Trace 
+ 
Trace 
Trace 
Trace 
Trace 
Trace 
Trace 

97.3 
70.0 

+ 
+ 
Trace 
Trace 
Trace 

V.F.T. 

Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Trace 
Trace 

Seg- 

Neg. 
Neg. 
Neg. 
Neg. 
Trace 
Neg. 
Trace 
Trace 
Trace 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Neg. 
Trace 
Neg. 
Trace 
Neg. 
Neg. 
Neg. 
V.F.T. 
Trace 
Trace 

0.200 

49 

6.200 
6.200 

0.156 

o.isb 

"55 

54 

6.192 



Hospital. 

+  +  +  +=  Large  amount. 
+  +=  Moderate  amount. 
+=  Small  Amount. 
V.F.T.=Very  faint  trace. 


**R= Regular  mixed  diet. 

F.F.= Fat-free  diet. 

A.T.=  Starvation. 

I.S.  =  Intermittent  starvation. 
tPatient  fed  by  mistake. 
ttPatient  eating  outside. 


230  BLOOD   AND   URINE    CHEMISTRY 

cells.  Ehrlich96  proved  that  the  peculiar  hyaline  degeneration 
described  by  Armanni  was  due  to  the  deposition  of  glycogeii  in 
the  cells  and  that  the  so-called  "glycogenic  degeneration"  could 
be  found  in  the  majority  of  cases.  Albertoni  and  Pisenti97  fed 
rabbits  and  dogs  with  acetone,  producing  first  albuminuria  and 
eventually  hyaline  changes  analogous  to  those  already  described, 
without,  however,  causing  glycogenic  degeneration.  Trambusti 
and  Nesti98  were  able  to  produce  similar  lesions  in  phlorizinized 
dogs  when  the  animals  excreted  appreciable  amounts  of  acetone 
in  the  urine.  Even  though  these  anatomic  changes  were  described 
and  even  though  we  know  that  the  diabetic  kidney  is  under  the  in- 
fluence of  a  diuretic,  that  edema  may  occur  in  diabetes,  that  the 
urine  of  these  patients  shows  on  the  verge  of  coma  hyaline  and 
granular  casts,  but  little  attempt  was  made  before  the  publica- 
tion of  Fitz,  to  note  the  renal  function  in  diabetes  under  varying 
conditions  of  glycosuria,  hyperglycemia  and  acidosis.  lie  studied 
this  function  by  means  of  the  McLean  adaptation  of  the  Ambard 
coefficient,  the  seventy-two  minute  period  specimen  of  urine;  by 
analysis  of  the  blood  for  urea,  with  sugar  analysis  by  the  Benedict- 
Lewis  method,  the  analysis  of  the  blood  plasma  for  sodium  chlo- 
ride by  the  McLean  and  Van  Slyke99  method  and  the  combining 
power  of  the  plasma  for  carbon  dioxide  by  Van  Slyke 's  method. 
Alveolar  air  samples  were  collected  according  to  Plesch's  method 
and  were  analyzed  in  a  Haldane100  gas  analysis  instrument.  He 
found  as  a  result  of  these  investigations  that  the  urea  index  in 
the  majority  of  cases  tended  to  be  normal  or  abnormally  high. 
This  was  in  part  due  to  the  rapid  rate  of  water  elimination  which 
characterized  many  of  the  cases  of  diabetes  which  were  studied. 
Such  diuretic  effect  \vas  not  dependent  on  acidosis  or  glycosuria, 
but  seemed  to  be  more  or  less  associated  with  hyperglycemia. 
the  urea  index  in  six  cases  of  fatal  diabetic  coma  was  abnor- 
mally low.  Renal  function  appeared  to  become  progressively 
worse  as  the  coma  persisted.  One  patient  had  a  pronounced  ac- 
cumulation of  acetone  in  the  blood  plasma  without  a  correspond- 
ing increase  in  excretion,  and  five  patients  showed  a  glycemia 


'"Ehrlich:      Ztschr.   f.   klin.   Med.,    1883,   vol.    vi,   p.    33. 

"'Albertoni   and   Pisenti:      Arch.    f.   cxp.   Path.   u.    Pharm.,    1887,   vol.    .xxiii,   p.    393. 
""Trambusti   and   Nesti:     Zicgler   Heit.   z.   path.   Anat,    1893,   vol.    \iv,   p.    337. 
""McLean  and   Van   Slyke:     Jour.   Riol.   Chem.,   1915,  vol.   xxi,  p.  361. 
"""Ilaldanc:      Methods   for   Gas    Analysis,    1912. 


BLOOD   SUGAR  231 

which  seemed  proportionally  higher  than  the  corresponding  gly- 
cosuria.  These  cases  suggest  that  fatal  diabetic  coma  is  accom- 
panied by  impaired  renal  function  in  which  more  than  one  of  the 
kidney's  functions  are  involved.  The  cause  of  the  complication 
is  not  known.  In  diabetes  the  blood  plasma  chloride  was  found 
by  Fitz  to  be  usually  lower  than  would  be  calculated  from  the 
chloride  excretion  according  to  the  formula  of  Ambard  and  Weill. 
This  abnormality  of  excretion  is  not  necessarily  associated  with 
acidosis,  an  abnormal  urea  index,  the  degree  of  glycemia  or  gly- 
cosuria.  Edema  due  to  sodium  chloride  retention  may  be  en- 
countered in  diabetes.  In  one  case  of  Fitz's  it  was  accompanied 
by  a  falling  urea  index  and  by  an  increase  of  acetone  in  the  blood 
without  acidosis,  as  evidenced  by  an  abnormally  lower  alveolar 
carbon  dioxide  tension.  The  edema  cleared  up  promptly  when 
the  sodium  chloride  intake  was  restricted.  Edema  following  the 
administration  of  sodium  bicarbonate  is  probably  due  to  sodium 
chloride  retention,  as  the  plasma  chloride  diminishes  and  at  the 
same  time  the  excretion  of  sodium  chloride  in  the  urine  is  les- 
sened when  the  drug  is  given. 


CHAPTER  XXVIII. 
ACIDOSIS. 

AVc  will  now  consider  acidosis,  its  cause,  its  symptomatology, 
its  significance,  its  recognition  by  blood  and  urinary  findings.  In 
acidosis  it  is  not  meant  that  the  reaction  of  the  blood  actually 
changes  from  its  alkaline  or  neutral  reaction  to  acid  reaction. 
This  is  impossible,  for  life  cannot  be  sustained  if  an  acid  condi- 
tion of  the  blood  occurs.  In  the  very  last  stages  of  life,  practi- 
cally in  extremis,  an  acid  condition  of  the  blood  occurs,  but  un- 
der no  other  circumstances. 

It  must  be  remembered  that  the  neutrality  of  the  blood  de- 
pends upon  the  mixture  of  carbonic  acid,  carbonates,  and  phos- 
phates in  the  blood  and  that  these  seem  to  remain  at  constant 
values  even  though  the  exogenous  source  of  alkalies  or  acids 
is  increased  or  diminished.  This  was  shown  by  Henderson.1  Car- 
bon dioxide  is  also  thrown  off  from  the  lungs  and  the  urine  in 
health  is  acid  in  reaction ;  this  helps  in  maintaining  the  alkalinity 
of  the  blood.  The  physiology  of  the  respiratory  center  is  most 
interesting  for  when  the  amount  of  acid  increases  in  the  body, 
there  is  a  quick  stimulation  of  these  centers  with  the  result  that 
more  C02  is  thrown  out  and  the  acid  condition  of  the  blood  is 
prevented  from  assuming  larger  proportions.  Any  excess  of  acids 
induces  this  phenomenon.  When  the  acidity  of  the  blood  is 
threatening,  there  is  a  quick  call  on  the  ammonia.  It  is  only 
when  the  ammonia  is  being  used  up,  that  "acidosis"  supervenes. 
In  the  course  of  normal  metabolism  we  know  that  the  ammonia 
of  the  body  is  converted  into  urea  and  eliminated  as  such,  but  the 
supervening  acidosis  takes  up  some  of  this  ammonia  and  keeps  the 
blood  alkaline.  Application  of  principles  calling  for  an  estima- 
tion of  the  alveolar  carbon  dioxide  tension  of  course  gives  valu- 
able information  about  acidosis.  In  a  very  recent  publication, 
Marriott2  has  called  attention  to  a  simple  method  for  the  dc- 

'Hcnderson:  Krgcb.  d.  Physiol.,  1909,  vol.  viii,  p.  254;  Science,  New  York,  1913,  vol. 
xxxvii,  p.  389. 

2Marriott:     Jour.   Am.   Mcd.   Assn.,   May  20,    1916. 


ACIDOSIS  233 

termination   of  this   tension.      We   shall   fully   cover   this  later. 

Rowland  and  Marriott3  assert  that  the  term  is  loosely  used,  that 
acidosis  is  spoken  of  when  acetone  bodies  appear  in  the  urine. 
This  is  not  necessarily  true.  We  must  remember  that  the  regula- 
tors of  the  alkalinity  of  the  blood  are  (1)  sodium  bicarbonate,  oc- 
curring in  plasma  and  cells,  (2)  the  acid  and  alkaline  phosphates 
of  sodium  and  potassium  found  in  the  red  blood  cells,  and  (3) 
the  proteins.  Acid  in  the  shape  of  carbonic  acid  is  formed  in  the 
tissues.  Respiration  lowers  the  concentration  of  C02  in  the 
lungs  and  allows  the  higher  concentrations  in  the  tissues  to 
escape  into  the  lungs  and  be  removed.  Concentration  is  highest 
in  the  tissues,  lower  in  the  blood,  and  lowest  in  the  lungs.  Hen- 
derson4 calls  carbonates  of  the  blood  the  first  line  of  defense 
against  acidosis.  Dyspnea  or  hyperpnea,  or  increased  pulmonary 
ventilation,  is  the  greatest  aid  for  the  liberation  of  carbon  dioxide 
from  the  body. 

A  second  line  of  defense  is  the  capacity  of  the  kidneys  to  ex- 
crete an  acid  urine  from  a  neutral  blood.  They  remove  acid 
phosphate  and  save  base  with  each  molecule  of  acid  phosphate 
that  they  excrete.  A  third  line  of  defense  is  furnished  by  the 
proteins.  Proteins  can  combine  with  appreciable  amounts  of 
either  acids  or  alkalies  without  undergoing  any  marked  changes 
in  reaction.  Another  line  of  defense  is  the  ammonia  of  the  body. 
The  body  can  neutralize  acid  by  producing  ammonia.  This  oc- 
curs at  the  expense  of  the  urea.  Aside  from  the  interest  we  have 
in  acidosis  as  part  and  parcel  of  our  study  of  diabetes  mellitus, 
acidosis  occurs  in  children  in  connection  with  other  conditions. 

Quoting  from  Howland  and  Marriott:5  "Even  when  no  evi- 
dence of  disease  can  be  detected  to  which  the  acidosis  can  be  re- 
ferred, acidosis  may  be  found.  For  instance,  a  boy  of  six  was 
suddenly  taken  ill  with  high  fever.  Inside  of  twelve  hours  he 
was  brought  to  the  hospital  with  great  dyspnea  of  the  ajr-hunger 
type.  Physical  examination  was  quite  negative  except  for  a 
purulent  otitis  media.  All  the  tests  made  indicated  acidosis. 
The  bicarbonate  of  the  blood  was  greatly  reduced.  The  reaction 

3Howland,  John,  and  Marriott,  W. :  Bull.  Johns  Hopkins  Hosp.,  March,  1916,  vol. 
xxvii,  No.  301. 

4Henderson:     Am.   Jour.    Physiol.,    1908,   vol.   xxi,  p.   427. 

5Howland,  John,  and  Marriott,  W. :  Bull.  Johns  Hopkins  Hosp.,  March,  1916,  vol.  xxvii, 
Xo.  301. 


234  BLOOD   AND    URINE    CHEMISTRY 

of  the  blood  had  shifted  markedly  toward  acidity  and  yet  the 
acetone  bodies  in  the  blood  were  not  greatly  increased.  The 
tolerance  for  alkalies  was  enormously  increased.  Though  he  took 
by  mouth  20  grams  of  soda  and  6  grams  by  rectum  without  vomit- 
ing or  diarrhea,  no  change  in  the  reaction  of  the  urine  was  pro- 
duced thereby.  But  the  alkalies  had  a  profound  influence  upon 
his  condition;  his  respirations  diminished  in  rapidity  and  depth, 
the  evidences  of  acidosis  to  be  obtained  by  the  various  tests 
rapidly  disappeared  and  he  made  an  uninterrupted  and  appar- 
ently complete  recovery;  for  he  now  seems  entirely  well  and  has 
been  so  for  six  months. 

"We  may  then  say  that  acidosis  is  not  an  uncommon  condition 
in  infancy  and  childhood;  that  while  it  is  especially  frequent  in 
the  severe  diarrheas  of  infancy,  it  may  appear  with  a  variety  of 
diseases,  and  sometimes,  apparently,  alone.  To  recognize  it  with 
older  children  is  not  very  difficult.  The  character  of  the  respira- 
tion is  usually  sufficient  to  arrest  one's  attention  and  one  or  two 
relatively  simple  laboratory  tests  will  quickly  determine  the 
question  one  way  or  the  other.  With  infants  who  are  irritable, 
restless  and  crying,  it  is  much  more  difficult  to  say  whether  hyperp- 
nea  is  present;  and  yet  with  them  it  is  most  important  to  make 
the  diagnosis  early,  for  the  reason  that  acidosis  is  such  a  fatal 
complication  of  diarrheal  disease  in  infancy.  Older  children  re- 
act promptly  and  often  permanently  to  alkali  therapy.  It  may 
be  possible  to  stop  the  clinical  and  laboratory  evidences  of  acidosis 
in  infants,  but  the  patients  usually  die.  Why  they  do  cannot 
be  determined  at  the  present  time.  Many  normal  processes  have 
undoubtedly  been  inhibited,  perhaps  permanently,  and  many  ab- 
normal ones  stimulated.  A  restoration  to  normal  conditions 
seems  nearly  impossible.  For  this  reason  we  should  not  wait 
until  acidosis  can  be  demonstrated.  From  the  beginning  we 
should  give  bicarbonate  of  soda  to  infants  with  severe  diarrhea 
in  sufficient  quantity  to  render  the  urine  alkaline  and  keep  it  so. 

"We  may  lay  it  down  as  a  general  maxim  that  as  hyperpnea 
indicates  acidosis,  so  hyperpnea  indicates  alkali  therapy,  and  this 
for  infants  or  older  children.  The  alkalies  may  be  given  by 
mouth,  by  rectum,  subcutancously,  or  intravenously.  Vomiting 
and  diarrhea  frequently  render  their  administration  by  mouth  or 
by  rectum  out  of  the  question.  Then  one  of  the  other  methods 


ACIDOSIS  235 

must  be  employed.  Intravenous  administration  is  the  method 
of  choice,  especially  when  rapidity  of  action  is  desired — and  with 
acidosis  rapidity  of  action  is  always  desired. 

''The  superior  longitudinal  sinus,  as  advised  by  Marfan,  Tobler 
and  Helmholz,  is  available  with  infants,  or  the  external  jugular 
or  femoral  veins.  With  older  children,  a  vein  in  the  arm  can  of- 
ten be  employed.  If  facilities  for  the  intravenous  injection  of 
alkali  are  not  at  hand,  the  injection  may  be  made  subcutaneously, 
with  care  that  the  bicarbonate  has  not  been  transformed  into  the 
carbonate,  else  severe  sloughing  of  the  tissues  may  result.  A  four 
per  cent  solution  is  usually  employed  for  intravenous  use  and  a 
two  per  cent  solution  for  subcutaneous  use.  The  quantity  to  be 
injected  depends  upon  the  size  of  the  child,  the  severity  of  the 
symptoms  and  the  effect  produced,  but  the  amount  is  always 
large.  It  must  be  given  until  the  urine  becomes  alkaline;  even  in 
infants  under  one  year,  as  much  as  10  gm.  in  24  hours  may  be 
required. 

"With  the  cases  of  acetone-body  acidosis  with  no  sugar  in  the 
urine  and  with  a  low  sugar  content  in  the  blood,  glucose  by  rec- 
tum, subcutaneously  or  intravenously,  seems  clearly  indicated  in 
addition  to  the  alkali.  With  all  forms  water  is  urgently  re- 
quired, especially  with  infants  who  are  dessicated  as  a  result  of 
the  vomiting  and  diarrhea. 

"Much  remains  to  be  learned  regarding  acidosis.  The  presence 
of  abnormal  acids  explains  the  origin  of  some  forms,  but  there  are 
others  that  are  in  nowise  understood.  Are  there  abnormal  acids 
whose  presence  has  not  been  detected?  Are  normal  acids  formed 
in  excess?  Are  bases  lost?  Does  the  kidney  fail  to  excrete  suf- 
ficient acid?  These  are  a  few  of  the  questions  at  present  unan- 
swered that  must  be  answered  before  our  knowledge  of  acidosis 
can  be  considered  in  any  way  complete.  Much  has  been  learned 
in  the  last  few  years ;  with  the  present  greatly  stimulated  interest 
in  the  subject,  we  may  confidently  expect  that  the  future  will 
provide  answers  to  many  of  the  questions  that  now  seem  obscure. ' ' 

Our  interest  in  acidosis  is  intimately  connected  with  the  dia- 
betic where  the  sugar  can  be  utilized  and  the  acetone  bodies  ac- 
cumulate in  the  blood.  The  study  of  the  hydrogen-ion  concen- 
tration of  blood  will  throw  light  on  diabetic  acidosis:  Marriott 
has  pointed  out  a  method  for  this  study  (see  page  68).  The  car- 


236  BLOOD    AND    URINE    CHEMISTRY 

bon  dioxide  tension  of  alveolar  air  should  also  be  studied;  Mar- 
riott's method  determines  this  and  thus  estimates  the  degree  of 
severity  of  the  acidosis  and  the  results  of  the  treatment  of  the  same. 
This  is  a  very  excellent  way  of  arriving  at  such  a  conclusion,  but, 
it  must  be  remembered  as  Marriott  states  in  his  monograph,6  that, 
' '  Changes  in  the  pulmonary  epithelium  such  as  would  prevent  the 
air  in  the  lungs  from  coming  in  equilibrium  with  the  blood  in  the 
capillaries,  would,  of  necessity,  affect  the  composition  of  the 
alveolar  air.  Since  very  little  is  known  as  yet  regarding  the  exact 
effect  of  such  changes,  one  is  hardly  justified  in  drawing  conclusions 
regarding  acidosis  from  the  composition  of  the  alveolar  air  in 
patients  with  pulmonary  affections." 

The  neutralization  of  the  acidity  that  threatens  in  acidosis  oc- 
curs also  through  the  ammonia  reserve,  as  alluded  to  above. 
It  has  been  repeatedly  stated  by  writers  011  the  prevention  of  acid- 
osis that  the  consumption  of  fats  must  be  stopped,  in  fact,  in 
the  preliminary  preparation  of  a  patient  for  the  Allen  treatment, 
fats  must  be  excluded  so  as  to  prevent  or  lessen  the  chance  of 
acidosis  from  long-continued  fasting.  Why  is  this  true?  The 
metabolism  of  fats  will  easily  explain  this:  in  the  absence  of  the 
proper  carbohydrate  balance  or  tolerance  (which  is  the  situation 
that  exists  in  severe  diabetes)  the  substances  that  result  from  the 
cleavage  of  the  higher  fatty  acids  (such  as  stearin,  palmitin)  of 
fat,  are  transformed  into  oxybutyric  acid  and  diacctic  acid,  in- 
stead of  pursuing  the  normal  path  of  transformation  into  butyric 
acid.  There  is  no  further  oxidation.  Also  these  acids,  oxybutyric 
and  diacctic,  may  -arise  from  certain  of  the  ammo-acids,  leucinc, 
tyrosine,  phenylalin,  which  occur  when  protein  is  split  up.  These 
organic  acid  derivatives  of  the  fat  and  protein  matter  of  the  body 
furnish  the  basis  for  the  formation  of  the  so-called  acetone  bodies 
which  arc  acetone,  bcta-oxybutyric  acid  and  diacelic  acid.  Their 
formulas  are  as  follows: 

CH3  -  CO  -  CH3  =  Acetone. 

CH3  -  CHOH  -  CH2  -  COOH  =  Bcta-oxybutyric   acid. 

CH3  -  CO  -  CH,  -  COOH  =  Diacetic  acid   (accto-acctic  acid) . 

When  these  bodies  appear  in  the  blood  in  excess  we  have  acidosis, 
but  it  must  again  be  stated  that  they  do  not  produce  an  acid  reac- 

6Marriott:     Jour.   Am.   Mcd.  Assn.,   1916,  vol.  Ixvi,  p.    1594. 


ACIDOSIS  237 

tion  of  the  blood.  When  they  arc  excreted  in  the  urine  we  speak 
of  ketonuria  or  acetonuria.  As  a  matter  of  fact  no  acetone  is 
eliminated  as  such  by  the  kidneys :  they  do  eliminate  diacetic  acid, 
but  from  this  acetone  is  formed  in  the  urine.  This  chemical  forma- 
tion is  easy  to  follow ;  it  simply  consists  in  the  diacetic  acid  throw- 
ing off  the  molecule  COOH,  resulting  in  acetone.  Emphasis  must 
be  laid  upon  the  fact  that  acidosis  does  not  occur  when  the  body 
is  easily  and  normally  burning  up  its  sugar.  It  is  when  it  can 
no  longer  do  so,  that  the  chemical  processes  already  explained  oc- 
cur. The  fats  under  normal  condition  are  burned  up  in  the  elab- 
oration of  the  carbohydrate  metabolism,  but  when  the  carbohy- 
drate metabolic  processes  are  in  abeyance,  then  the  fats  go  through 
their  imperfect  evolution  to  diacetic  acid  and  beta-oxybutyric 
acid  and  acetone,  i.  e.,  acidosis  then  occurs. 

We  have  .called  attention  to  the  fact  that  the  ammonia  is  called 
upon  to  "suppress"  the  acidosis.  One  of  the  methods  for  de- 
termining the  ammonia  output  which  in  turn  will  guide  us  in 
estimating  the  degree  of  acetonuria,  is  to  determine  the  amount 
of  bicarbonate  of  sodium  necessary  to  render  the  urine  alkaline 
or  amphoteric.  Normally  from  5  to  10  grams  of  bicarbonate  of 
sodium  will  render  the  urine  alkaline.  In  mild  acidosis,  20  grams 
are  required ;  in  severer  cases  from  30  to  40  grams ;  and  in  ex- 
treme cases  40  grams  or  more.  In  coma,  when  urine  is  excreted, 
it  is  usually  impossible  to  neutralize  the  urine  or  make  it  ampho- 
teric, no  matter  how  much  sodium  bicarbonate  is  used.7 

Another  method,  however,  wrhich  is  a  much  more  delicate  test 
for  acidosis  than  any  of  the  urine  tests  or  the  sodium  bicarbonate 
test  just  described,  is  the  estimation  of  the  carbon  dioxide  com- 
bining power  of  blood  plasma,  as  described  by  Van  Slyke.  Here 
we  have  a  ready  method  for  exactly  and  quickly  determining  the 
ability  of  the  patient's  blood  plasma  to  take  up  carbon  dioxide. 
When  the  ability  of  the  patient's  plasma  is  impaired  in  taking 
up  carbon  dioxide,  then  we  have  an  acidosis.  Thus  blood  plasma, 
normally,  has  the  capacity  to  combine  with  65  per  cent  or  more 
of  the  carbon  dioxide,  which  can  be  thrown  into  it  in  the  form 
of  alveolar  air.  When  this  percentage  falls  below  50,  we  must 
consider  the  individual  in  a  state  of  acidosis.  This  method  is 


TRarker:     Monographic  Medicine,  vol.   iv,   p.   820. 


238  BLOOD    AND    URINE    CHEMISTRY 

equal  in  efficiency  to  the  methods  of  determination  of  the  blood 
hydrogen-ion  concentration  of  Marriott  or  the  method  of  determina- 
tion of  the  carbon  dioxide  tension  of  alveolar  air.  The  character- 
istic readings  on  the  Van  Slyke  apparatus  are  anywhere  below  50 
in  marked  acidosis.  Thus  the  carbon  dioxide  combining  power  in 
a  case  of  diabetes  has  been  seen  to  drop  from  50  to  30.  The  ad- 
ministration of  alkalies  has  a  profound  influence  upon  it.  This 
brings  us  to  a  short  consideration  of  the  use  of  physical  and 
chemical  forces  in  combating  this  condition.  Inasmuch  as  the 
acetone  bodies  result  from  the  imperfect  and  incomplete  break- 
ing up  of  the  fat  molecule,  it  is  rational  to  interdict  the  use  of 
fats.  Secondly,  the  condition  occurs  as  a  result  of  imperfect  car- 
bohydrate metabolism.  The  glucose  is  not  being  burnt  up.  We 
try  to  burn  up  the  carbohydrates.  It  is  said  that  alcohol  assists 
in  the  burning  up  of  glucose,  and  therefore  should  be  tried.  Since 
alkaline  substances  taken  into  the  body  will  help  to  render  the 
urine  amphoteric,  we  must  quickly  throw  into  such  a  case  as 
much  sodium  bicarbonate  as  possible.  As  much  as  a  teaspoonful 
every  half  hour  in  water  should  be  given  to  a  patient  with  im- 
pending diaceturia  until  his  urine  becomes  amphoteric. 

Marriott,  Levy,  and  Eowntree8  have  described  their  method  for 
determination  of  the  hydrogen-ion  concentration  of  the  blood,  as 
given  on  page  68. 

It  might  be  advantageous  to  amplify  their  work  here  regarding 
the  variations  in  the  hydrogen-ion  concentration  of  the  blood. 
They  maintain  that  human  blood  as  it  exists  in  the  body  is  faintly 
alkaline  in  reaction,  that  is,  it  has  a  hydrogen-ion  concentration 
only  slightly  less  than  that  of  pure  water,  and  this  degree  of 
alkalinity  tends  to  be  maintained  even  when  considerable  quantities 
of  acids  are  produced  within  the  body,  or  are  introduced  from 
without.  Acidosis  may  be  recognized  in  various  ways,  by  an 
increase  in  the  ammonia  coefficient  in  the  urine,  decrease  of  carbon 
dioxide  tension  of  alveolar  air,  the  finding  of  abnormal  acids  in 
the  blood  and  urine,  increased  alkali  tolerance  and  by  dimin- 
ished titratablc  alkalinity  of  the  blood  scrum,  by  changes  in  the 
hemoglobin  dissociation  curve  and  by  actual  determination  of 
the  hydrogen-ion  concentration  of  the  blood.  A  change  in  the 
hydrogen-ion  concentration  of  the  blood  indicates  a  failure  of  the 

sMarriott,  Levy,   and   Rowntree:      Arch.   Int.   Mecl.,    1915,  vol.   xvi,   p.   388. 


ACIDOSIS  239 

protective  mechanism  and  the  onset  of  acidosis.  It  is  in  this  con- 
nection that  the  determination  of  the  hydrogen-ion  concentration 
of  the  blood  according  to  the  technic  given  on  page  68  is  of 
value.  With  the  use  of  this  method,  a  series  of  bloods  from  normal 
and  pathologic  cases  were  studied  with  the  following  results: 

1.  Normal  individuals:  twenty-five  cases.     A.  Serum;  twenty- 
four  of  the  twenty-five  cases  read  between  7.6  and  7.8,  in  one  in- 
stance 7.9  was  the  record : 

pH  Cases 

7.6  4 
7.65  1 

7.7  5 
7.75  5 

7.8  9 

7.9  1 

B.  Whole  blood   (oxalated  by  collection  in  tubes  containing  a 
little  dry  powdered  sodium  oxalate,  free  from  carbonate)  ;  nine- 
teen determinations.     These  all  read  between  7.4  and  7.6 : 

pH  Cases 

7.4  3 
7.45  2 

7.5  4 
7.55  5 

7.6  5 

The  slightly  greater  acidity  of  whole  blood  as  compared  with 
serum  has  been  recognized  by  others  and  is  due  possibly  to  the 
fact  that  hemoglobin  and  especially  oxyhemoglobin,  behaves  as  a 
weak  acid. 

C.  Defibrinated  blood:    These  writers  used  early  in  their  work 
defibrinated  blood  run  in  parallel  series  with  serum  and  oxalated 
whole  blood.    No  additional  information  was  gained  by  using  de- 
fibrinated  blood,    it   complicated   the  work   and   so   its   use   was 
abandoned. 

2.  Miscellaneous  medical  cases  were  studied,  sixty-three  deter- 
minations in  52  cases,  comprising  the  following  diseases :  nephritis, 
acute  and  chronic,    diabetes    mellitus,    myocardial    insufficiency, 
syphilis,  arthritis,  tuberculosis,  etc.     With  respect  to  the  serum 
of  these  cases,  sixty  of  the  sixty-three  determinations  read  be- 
tween 7.6  and  7.8.    With  whole  blood,  thirty-three  determinations 
gave  thirty-one  between  7.4  and  7.6. 

3.  Acidosis  cases  were  studied,  eight  cases  with  fifteen  determina- 


240 


BLOOD    AND    URINE    CHEMISTRY 


tions.    The  general  conclusions  respecting  the  value  of  this  method 
of  estimating  acidosis  are  as  follows : 

A.  The  indicator  method  of  determining  hydrogen-ion  concen- 
tration is  made  applicable  to  blood  and  serum  by  utilization  of 
dialysis  through  a  collodion  membrane,  which  excludes  the  dis- 
turbing influences  of  color  and  of  proteins.  The  method  is  simple, 
accurate,  rapid,  and  well  adapted  for  clinical  work. 


R.-fl J7N, 


Fig.    64.— Fridc 


B.  The  tcchnic  consists  of  dialyzing  3  c.c.  of  blood  or  serum 
at  room  temperature  against  3  c.c.  of  0.8  per  cent  salt  solution  for 
five  minutes,  adding  an   indicator   and  comparing  with   colored 
standard  phosphate  mixtures  of  known  hydrogen-ion  concentra- 
tion. 

C.  Phenolsulphonphthalein  is  employed  as  the  indicator  in  this 


ACIDOSIS  241 

method.  It  is  found  to  exhibit  easily  distinguishable  variations 
in  quality  of  color,  with  minute  differences  in  hydrogen-ion  con- 
centration between  the  limits  of  pH6.4  and  pH8.4. 

D.  Oxalated  blood  from  normal  individuals  gives  a  dialysate 
with  a  pH  varying  between  7.4  and  7.6,  while  that  of  serum  ranges 
from  7.6  to  7.8. 

E.  Variations  from  these  figures  toward  the  acid  side  were  en- 
countered only  in  conditions  which  clinically,  and  from  the  stand- 
point of  laboratory  findings,  evidenced  an  acidosis. 

F.  In  a   small  series  of  clinical  acidoses,  the  serums  varied  from 
7.55  to  7.2  and  oxalated  blood  from  7.3  to  7.1.     In  experimental 
acidosis  in  dogs,  a  pH  of  6.9  was  encountered  in  both  serum  and 
blood  just  before  death. 

A  method  for  determination  of  carbon  dioxide  in  alveolar  air 
is  that  of  Fridericia  (Fig.  64).  This  method  does  not  involve  the 
use  of  expensive  apparatus,  can  be  transported  to  the  bedside, 
and  only  occupies  about  fifteen  minutes.  It  requires  the  coopera- 
tion of  the  patient  and  consequently  cannot  be  used  when  the  pa- 
tient is  in  coma,  but  when  this  occurs  the  Van  Slyke  and  urinary 
findings  will  suffice.  Fridericia9  described  his  method  in  1914. 
Horner10  describes  the  method  as  follows : 

"This  method  possesses  the  advantage  of  being  simple  and  in- 
volving the  use  of  apparatus  which  may  be  easily  transported  to 
the  bedside.  One  hundred  cubic  centimeters  of  alveolar  air  are 
collected  in  a  closed  chamber  and  then  cooled  from  the  tempera- 
ture of  the  body  to  that  of  the  room.  The  carbon  dioxide  in  this 
air  is  then  absorbed  with  a  20  per  cent  aqueous  solution  of  potas- 
sium hydrate,  thereby  creating  a  partial  vacuum,  which  in  turn 
is  equalized  with  water.  This  water  is  then  subjected  to  atmos- 
pheric pressure,  when  the  amount  of  carbon  dioxide  replaced  by 
water  can  be  read  in  percentage  of  atmospheric  air  by  reading 
the  height  in  centimeters  to  which  the  column  of  water  has  risen 
in  the  closed  100  c.c.  chamber.  This  percentage  may  be  changed 
to  millimeters  of  mercury  pressure  by  multiplying  the  difference 
between  barometric  pressure  at  the  time  of  -the  test,  and 
this  varies  in  Boston  between  700  mm.  and  750  mm.,  and  the  ten- 
sion of  aqueous  vapor  at  37.5°  C.  which  is  48  mm.  mercury. 


9Fridericia:     Berl.  klin.   Wclmschr.,   1914,  p.   1268. 

10Horner:     Boston  Med.  and  Surg.  Jour.,   1916,  vol.  clxxv,  No.   5. 


242  BLOOD    AND    URINE    CHEMISTRY 

This  will  make  a  factor  which  lies  between  718  and  702.  As  the 
reading  of  760  is  much  the  more  common  at  sea  level,  for  clinical 
purposes  the  factor  715  may  be  used  satisfactorily.  The  patient 
should  be  in  the  same  position  and  quiet  for  ten  minutes  prior  to 
the  performance  of  the  test. 

"After  a  normal  inspiration,  the  end  (A)  of  the  apparatus  is 
inserted  between  the  lips,  and  the  patient  is  instructed  to  expire 
forcibly  through  the  apparatus,  with  cocks  C  and  D  open,  so 
that  there  is  a  free  passage  from  A  to  B.  The  tube  remains  in 
the  mouth  throughout  the  entire  expiration  and  the  cock  C  is 
then  closed,  thus  retaining  between  cocks  C  and  D  the  last  100 
c.c.  of  expired  air.  (As  the  exchange  of  air  in  the  upper  respira- 
tory passage  is  200  c.c.  and  the  exchange  of  air  from  the  alveoli 
is  800  c.c.,  it  is  plain  that  with  any  care  at  all  a  sample  of  alveolar 
and  not  upper  respiratory  air  will  be  obtained.)  The  apparatus 
is  now  immersed  in  a  glass  tank  of  water  at  room  temperature 
and  allowed  to  remain  there  five  minutes.  The  best  way  to  ob- 
tain water  at  room  temperature  is  simply  to  keep  the  glass  tank 
in  the  room  with  the  patient  for  several  hours  before  the  test, 
though  with  an  ordinary  thermometer  one  can  easily  adjust  the 
temperature  of  the  water  to  that  of  the  room.  At  the  end  of  five 
minutes,  about  10  c.c.  of  20  per  cent  aqueous  solution  of  potas- 
sium hydrate  is  poured  into  the  apparatus  through  the  orifice  B. 
A  little  of  this  potassium  hydrate  will  leak  through  the  hole  in 
cock  D  to  chamber  CD.  Now  cock  D  is  turned  to  the  left  so  that 
chamber  CD  is  closed  and  chamber  BD  is  also  closed.  The  small 
amount  of  potassium  hydrate  in  chamber  CD  is  shaken  in  the 
chamber  for  a  moment.  Then  with  apparatus  in  upright  posi- 
tion, cock  D  is  turned  so  that  there  is  a  continuous  passage  from 
C  and  B,  and  the  amount  of  potassium  hydrate  which  will  run 
into  the  chamber  CD  is  allowed  to  do  so.  Now  cock  D  is  turned 
to  the  left  until  BDE  is  a  continuous  passage,  and  in  this  way 
potassium  hydrate  is  allowed  to  escape  into  the  water  tank. 
Chamber  CD  still  contains  2  or  3  c.c.  of  potassium  hydrate  solu- 
tion and  should  be  thoroughly  washed  with  this  solution.  Every 
point  in  the  surface  of  chamber  CD  must  be  touched  by  the  alka- 
line solution.  This  is  accomplished  by  shaking  very  thoroughly 
the  potassium  hydrate  in  chamber  CD.  The  apparatus  is  again 


ACIDOSIS  243 

immersed  in  the  tank  of  water,  cock  D  is  turned  to  the  left  until 
water  rises  into  CD  through  EDC,  and  the  apparatus  left  in  the 
water  five  minutes.  At  the  end  of  this  time,  the  apparatus  is 
raised  until  the  bottom  of  the  meniscus  of  the  water  in  chamber 
CD  is  level  with  the  top  of  the  water  in  the  tank.  Now  cock  D 
is  turned  to  the  right  until  water  runs  through  EDB  to  the  level 
of  water  in  chamber  CD,  which  is  now  closed.  Then  cock  D  is 
turned  further  to  the  right  until  CDB  is  a  continuous  chamber. 
The  apparatus  is  then  again  immersed  to  the  bottom  of  the  glass 
tank  and  the  water  in  the  arm  BD  of  the  apparatus  should  be  at 
the  same  level  with  the  water  in  the  chamber  CD  and  continuous 
with  it.  If  this  is  not  so,  then  the  amount  of  the  water  in  BD 
should  be  changed  until  it  reaches  the  height  of  the  column  of 
water  in  CD.  The  reading  is  now  taken  in  centimeters  of  the 
height  to  which  the  column  of  water  stands  in  CD,  and  this  is 
so  graduated  as  to  represent  the  percentage  of  C02  which  was 
absorbed  by  alkali  and  replaced  by  water.  This  completes  the 
test. 

"The  apparatus  is  prepared  for  the  next  test  by  opening  cock 
C  so  that  A  to  B  is  a  continuous  passage.  The  fluid  in  the  ap- 
paratus is  allowed  to  escape.  Orifice  B  is  put  under  the  faucet 
and  cold  water  allowed  to  run  through  the  apparatus,  taking  care 
to  shake  sufficiently  at  the  time  so  that  water  touches  all  of  the 
inside  of  the  apparatus.  Repeat.  Then  pour  through  orifice  B 
about  10  c.c.  of  4  per  cent  solution  boric  acid.  Rinse  the  ap- 
paratus very  thoroughly  with  the  acid  so  that  there  shall  be  no 
alkali  remaining  adherent  to  its  sides.  Wash  again  with  cold 
water.  Leave  the  apparatus  so  that  orifices  A  and  B  are  down, 
thereby  allowing  any  water  in  the  apparatus  to  drain  out." 

From  the  above  it  will  be  seen  that  the  necessary  apparatus 
consists  of  the  Fridericia  appliance,  a  glass  tank  whose 
depth  is  equal  to  the  length  of  the  Fridericia  apparatus*  and  a 
wash  bottle  containing  4  per  cent  solution  of  boric  acid.  It  is 
convenient  to  add  an  indicator,  such  as  alizarin,  or  litmus,  to  the 
alkaline  and  acid  fluids. 

Of  the  several  methods  recommended,  the  Van  Slyke  method 
of  estimation  of  the  carbon  dioxide  combining  power  of  blood 
plasma  is  manifestly  preferable,  inasmuch  as  it  does  not  entail 


244  BLOOD    AND    URINE    CHEMISTRY 

the  cooperation  of  the  patient  in  its  performance :  an  important 
point  when  dealing  with  unconscious  or  semiconscious  individuals. 
A  comparison  of  the  carbon  dioxide  tension  in  alveolar  air  by  the 
Flesh  method  with  the  amount  of  carbon  dioxide  in  the  venous 
blood  by  Van  Slyke 's  method  has  recently  been  published  by 
Walker  and  Frothlngham.11  They  collected  the  air  for  the  method 
of  Plesh,12  as  modified  by  Higgins,13  in  the  apparatus  described 
in  detail  by  Boothby  and  Peabody.14  In  this  method,  as  slightly* 
modified  by  Boothby  and  Peabody,  the  patients  could  not  always 
cooperate,  yet  they  claim  consistent  results  followed.  In  their 
use  of  the  Van  Slyke  method  they  slightly  modified  the  technic, 
i.  c.,  instead  of  forcing  alveolar  air  into  the  separately  funnel 
from  the  operator's  lungs,  they  employed  a  scparatory  funnel  of 
250  c.c.  capacity,  which  was  filled  from  a  spirometer  with  air  of  a 
known  carbon  dioxide  percentage.  Into  this  funnel  3  c.c.  of  the 
plasma  was  placed  and.  shaken  for  two  minutes.  One  c.c.  of  this 
mixture  was  then  immediately  put  through  the  process  already 
described  on  page  61.  The  figure  obtained  after  being  corrected 
for  temperature  and  barometric  pressure  represented  the  number 
of  milligrams  of  carbon  dioxide  in  1  c.c.  of  plasma.  Van  Slyke 
found  that  by  multiplying  this  figure  by  the  constant  35  he  ob- 
tained a  figure  comparable  to  that  obtained  for  the  carbon  dioxide 
tension  in  the  alveolar  air.  Their  observations  were  made  on  100 
different  cases  representing  thirty  different  types  of  disease.  A 
total  of  116  observations  in  all  were  made.  They  found,  for  in- 
stance, that  in  primary  anemia  the  carbon  dioxide  tension  in  the 
air  varied  in  different  cases  by  about  10  mm.  The  air  and  blood 
studied,  however,  did  not  vary  more  than  three  points.  In  a 
group  of  cases  of  Graves 's  disease,  the  carbon  dioxide  tension  was 
slightly  higher  than  the  blood  combining  power,  and  in  a  few 
the  difference  was  considerable.  In  typhoid  fever  the  results  were 
practically  identical.  In  two  cases  of  lung  abscess  the  results 
were  similar.  In  cases  of  chronic  nephritis  the  results  were  prac- 
tically alike.  It  was  found  that  when  the  carbon  dioxide  tension 
was  lowered  in  chronic  nephritis,  the  combining  power  of  the 

"Walker   and    Frothingham:      Arch.    Int.    Med.,    Sept.    15,    1916,    vol.    xviii,    No.    3,    pp. 
304-312. 

]2PIesh:  Ztschr.  f.  exper.  Path.  u.  Therap.,  1909,  vol.  Hi,  p.  380. 
"Higgins:  Carnegie  Inst.  of  Washington,  1915,  p.  168,  pub.  403. 
"Boothby  and  Peabody:  Arch.  Int.  Med.,  1914.  vol.  xiii,  p.  225. 


ACIDOSIS  245 

blood  plasma  was  similarly  lowered.  In  three  cases  of  syphilis 
the  results  were  identical.  Except  in  one  case  of  cardiac  dis- 
ease with  considerable  emphysema,  the  studies  were  alike  in  cases 
of  chronic  cardiac  disease.  Even  in  cases  of  pneumonia  where 
the  respirations  were  hurried  and  the  patients  could  not  co- 
operate very  well,  the  results  were  about  the  same.  In  acute  articu- 
lar rheumatism  there  were  similar  findings  except  that  there  was 
a  difference  in  one  "case  of  as  much  as  thirteen  points.  In  five 
out  of  six  cases  of  diabetes  the  air  and  the  blood  showed  practi- 
cally the  same  carbon  dioxide  tension.  The  sixth  one  showed  a 
more  marked  variation,  yet  both  determinations  showed  evidence 
of  an  acidosis,  so  that  the  variation  in  this  case  would  not  have 
been  at  all  misleading.  It  is  interesting  to  note  that  in  all  the 
cases  of  diabetes  which  showed  acidosis,  the  blood  was  lower  in 
carbon  dioxide  than  the  air.  In  other  diseases  the  same  story 
was  told.  In  summing  up  the  116  observations,  the  carbon  dioxide 
tension  by  the  Plesh  method  corresponded  with  that  estimated  in 
the  blood  by  the  Van  Slyke  method.  But  little- choice  from  the 
standpoint  of  accuracy  can  be  offered  with  these  two  methods, 
but  we  recommend  the  Van  Slyke  method  as  being  the  simpler. 

Summarizing,  it  may  be  stated  that  fasting  for  a  normal  in- 
dividual is  apt  to  be  followed  by  acidosis  quicker  than  for  a  dia- 
betic subject.  This  is  admirably  seen  in  the  Allen  treatment, 
where  fasting  is  not  followed  by  acidosis,  whereas  in  a  normal  in- 
dividual in  a  few  days  he  would  begin  to  show  the  characteristic 
signs  of  blood  and  urine  of  acidosis  and  ketonuria.  The  body  has 
certain  safeguards  against  acidosis  which  are,  the  removal  of 
acids  from  the  blood  through  the  lungs,  the  pulmonary  action 
being  increased  by  the  stimulation  of  excessive  acidity,  and  again 
the  fact  that  there  is  a  reaction  between  the  molecule  of  disodium 
phosphate  and  a  molecule  of  acid  by  which  the  sodium  carbonate 
of  the  blood  is  conserved  with  the  elimination  of  large  quantities 
of  acid.  The  amount  of  alkali  in  the  body  acts  as  a  factor  of  safety 
against  acidosis,  in  the  form  of  sodium  and  potassium  as  well  as 
the  calcium  and  the  magnesium  of  bones.  We  will  call  attention 
later  on  to  this  point  in  relation  to  the  mineral  metabolism  of  the 
urine.  The  factor  of  ammonia  in  the  body  must  again  be  em- 
phasized. This  is  due  to  the  fact  that  the  body  can  excrete  nitro- 


246  BLOOD    AND   URINE    CHEMISTRY 

gen  in  the  form  of  ammonia  from  the  proteins,  thereby  convert- 
ing some  of  the  endogenous  protein  whose  normal  destiny  is  urea 
into  ammonia.  It  must  be  remembered  that  one  gram  of  am- 
monia can  neutralize  five  times  as  much  beta-oxybutyric  acid 
as  one  gram  of  sodium  bicarbonate.15  The  retention  of  the  al- 
kalinity of  the  blood  is  possibly  best  explained  in  Rowland's  own 
language.10  "The  important  constituents  of  the  blood  so  far  as 
the  regulation  of  the  reaction  is  concerned  are  (a)  sodium  bi- 
carbonate, occurring  both  in  the  plasma  and  in  the  cells,  (b)  the 
acid  and  alkaline  phosphates  of  potassium,  found  almost  entirely 
within  the  red  blood  cells,  and  (c)  the  proteins. 

' '  Considering  the  blood  first  as  a  solution  of  bicarbonates :  a 
large  amount  of  acid,  carbonic  acid,  is  constantly  being  formed 
in  the  tissues.  It  must  be  removed  by  the  lungs,  but  first  it  must 
be  transported  to  the  lungs  by  the  blood.  This  stream  of  acid 
which,  with  an  adult,  in  the  course  of  the  day,  is  the  chemical 
equivalent  of  several  hundred  cubic  centimeters  of  concentrated 
hydrochloric  acid,  is  sufficient  to  render  acid  any  ordinary  solu- 
tion and  keep  it  permanently  acid.  If  this  should  happen  in  the 
blood,  life  would  of  course  be  impossible,  but  owing  to  the  laAvs 
that  govern  the  reaction  of  solutions  of  weak  acids  and  their  salts, 
the  solutions  of  bicarbonate  are  able  to  take  up  a  quantity  of  the 
acid,  carbon  dioxide,  without  appreciably  undergoing  a  change 
in  reaction.  Thus  there  can  be  transported  from  the  tissues  to 
the  lungs  and  so  continuously  eliminated  from  the  body,  a  very 
large  amount  of  acid.  This  steady  escape  of  acid  is  accomplished 
with  no  harm  and  with  no  strain  upon  the  organism.  The  respira- 
tory center  is  adjusted  to  assist  in  the  removal  of  the  carbon 
dioxide.  If  there  were  no  respirations  and  circulation  were  con- 
tinued, eventually  the  carbon  dioxide  concentration  would  be  the 
same  in  the  tissues,  in  the  blood  and  in  the  air  and  in  the  pul- 
monary alveoli. 

"But  the  respirations  lower  the  concentration  in  the  lungs 
and  thus  allow  the  carbon  dioxide  to  escape  from  the  tissues  where 
the  concentration  is  highest  by  the  blood  where  the  concentration 
is  lower,  to  the  air  in  the  lungs  where  the  concentration  is  low- 
est. The  respiratory  center  is  extraordinarily  sensitive  to  the 

15Toslin:     Loc.  cit.,  page   137. 

"Rowland:     Bull.  Johns  Hopkins  IIosp.,   1916,  vol.   xxvii,  p.   63. 


ACIDOSIS  247 

slightest  alteration  in  the  reaction  of  the  blood  toward  the  acid 
side,  so  that  an  increased  production  of  carbon  dioxide  in  the 
tissues,  such  as  occurs,  for  instance,  with  muscular  exercise,  and 
the  resultant  slight  excess  in  the  blood  is  answered  by  an  increased 
ventilation  of  the  lungs  which  removes  the  carbon  dioxide,  thereby 
bringing  the  reaction  of  the  blood  back  to  normal.  Other  acids, 
whether  formed  in  the  body  or  introduced  from  outside,  produce  a 
similar  effect.  They  displace  the  carbonic  acid  from  the  sodium 
bicarbonate  and  set  the  carbon  dioxide  free.  This  excess  of  car- 
bon dioxide  is  removed  by  the  increased  pulmonary  ventilation 
leaving  a  neutral  salt,  sodium  oxybutyrate,  or  chloride,  or  what 
not,  to  be  removed  by  the  kidneys.  Such  a  mechanism  allows  rela- 
tively huge  amounts  of  abnormal  acids  to  be  at  once  rendered 
innocuous  and  removed ;  for  instance,  NaHC03  +  HCL  =  NaCL  + 
H20  +  C02.  The  hydrochloric  acid  is  neutralized  and  the  result- 
ant sodium  chloride  is  removed  by  the  kidneys  while  the  carbon 
dioxide  is  given  off  by  the  lungs. 

"Henderson  calls  the  carbonates  of  the  blood  the  first  line  of 
defense.  Thus,  dyspnea,  more  properly  hyperpnea  or  increased 
pulmonary  ventilation,  under  abnormal  circumstances,  is  an  agent 
of  the  greatest  value  in  ridding  the  body  of  carbon  dioxide  and 
thus  keeping  the  reaction  within  normal  limits.  It  may  also  be 
remarked  that  liyperpnea  is  the  best  of  all  the  evidences  of  acidosis 
to  be  obtained  by  physical  examination  alone.  It  may  almost  be 
said  that  hyperpnea  means  acidosis. 

"If  the  bicarbonates  of  the  plasma  were  the  only  method  of 
defense  of  the  body,  the  organism  would  succumb  to  acidosis  as 
soon  as  the  bicarbonate  was  depleted  by  the  excretion  of  neutral 
salts  through  the  kidneys;  every  molecule  of  an  acid  would  rob 
the  body  of  a  molecule  of  bicarbonate.  The  second  mechanism 
here  comes  into  play  and  is  that  by  which  acids  may  be  removed 
leaving  behind  part  of  the  base  with  which  they  have  been  com- 
bined, this  base  being  available  for  further  neutralization.  The 
elimination  is  by  way  of  the  kidneys.  These  have  the  capacity  to 
excrete  an  acid  urine  from  a  nearly  neutral  blood.  They  remove 
acid  phosphate  and  save  base  with  each  molecule  of  acid  phos- 
phate that  they  excrete.  Thus,  although  alkali  is  eliminated  in 
the  urine,  it  is  much  less  than  would  be  the  case  without  this 


248  BLOOD    AND    URINE    CHEMISTRY 

specialized  kidney  activity,  and  can  readily  be  replaced  under 
normal  circumstances  by  the  alkali  of  the  food.  For  instance, 
with  the  introduction  of  a  foreign  acid — Na2HP04  +  HCL  = 
NaCL  +  NaH2P04 — the  hydrochloric  acid  is  neutralized,  the  sodium 
chloride  and  acid  sodium  phosphate  arc  excreted  by  the  kidneys 
or  the  following  reaction  may  take  place — Na2HP04  +  H20  +  COo 
=  NaII2P04  +  NaHC03.  By  this  method  the  sodium  bicarbonate 
reserve  of  the  body  is  renewed. 

"Henderson  and  Palmer  showed  the  magnitude  of  alkali  spar- 
ing very  prettily  by  titrating  with  alkali  the  acid  urine  back  to 
the  normal  reaction  of  the  blood.  The  alkali  spared  was  found  in 
normal  subjects  to  vary  in  terms  of  tenth  normal  alkali,  between 
200  and  800  c.c.  This  is  equivalent  to  saying  that  the  kidneys 
eliminate  from  200  to  800  c.c.  of  tenth  normal  acid  in  24  hours." 

A  very  authoritative  discussion  on  the  question  of  fat  in  dia- 
betes, in  relation  to  acidosis  particularly,  is  that  of  F.  M.  Allen, 
in  his  lecture  before  the  Harvey  Society  of  New  York,17  entitled 
"The  Role  of  Fat  in  Diabetes."  He  showed  the  development 
of  the  methods  of  these  problems  by  means  of  the  new  blood 
chemical  tests  which  we  have  already  described  in  Part  I  of 
this  work.  He  said  truly  that  it  was  a  fine  tribute  to  American 
science  that  every  one  of  these  tests  was  devised  or  perfected  by 
an  American  investigator.  Finally,  the  possibility  of  better 
study  of  the  problems  of  diabetes  was  greatly  increased  by  the 
ability  to  reproduce  in  dogs  conditions  almost  identical  with 
those  encountered  in  human  diabetes.  This  could  be  done  by  the 
surgical  removal  of  a  large  proportion  of  the  pancreas,  leaving 
the  remainder  in  communication  with  the  intestine  through  the 
pancreatic  duct.  This  operation  rendered  the  dogs  diabetic  and 
yet  retained  their  digestive  functions  through  the  preservation  of 
the  pancreatic  secretion. 

The  first  point  in  the  problem  of  the  role  of  fat  in  diabetes 
was  that  of  lipemia.  This  condition  was  almost  a  constant  find- 
ing in  severe  human  diabetes  and  might  be  present  to  a  slight 
degree  even  in  very  mild  cases.  The  same  was  found  to  be  true 
in  partially  dcpancrcatized  dogs.  Further,  diabetes  in  man  and 
the  partial  dcpancrcatization  of  dogs  were  the  only  conditions  in 

"•Allen,  F.  M. :     New  York  Mecl.  Jour.,  Nov.   18,   1916. 


ACIDOSIS  249 

which  a  high  degree  of  lipemia  was  found.  The  fat  might  be 
present  in  the  plasma  of  severe  cases  in  either  man  or  dog  in 
amounts  up  to  15  per  cent  or  over,  and  the  ability  to  produce  the 
condition  in  the  latter  afforded  ideal  conditions  for  the  study  of 
its  causation  and  significance.  It  had  long  been  believed  that  li- 
pemia was  due  to  a  diminution  in  the  lipase  present  in  the  blood, 
but  this  could  now  be  stated  to  be  incorrect  and  we  could  safely 
regard  the  lipase  as  quite  a  negligible  factor.  It  had  been  shown 
in  experimental  dogs  that  lipemia  varied  in  degree  largely  with  the 
digestive  power  of  the  animals,  that  the  fat  was  derived  in  great 
measure  from  the  food  fats,  and  that  lipemia  could  be  controlled 
largely  by  feeding.  The  fat  in  the  blood  was  chiefly  neutral  fat 
with  a  considerable  proportion  of  cholesterol,  which  ran  parallel 
to  the  former,  and  a  small  amount  of  lecithin. 

As  to  the  causation  of  lipemia,  experiments  on  the  partially  de- 
pancreatized  dogs  made  it  possible  to  say  definitely:  1.  Lipemia 
was  not  due  to  the  occurrence  of  hyperglycemia.  2.  It  was  not 
due  to  the  absence  of  carbohydrate  or  to  the  loss  of  sugar.  3.  It 
was  not  due  to  the  presence  of  acetone  bodies  or  to  the  change  in 
the  reaction  of  the  blood.  4.  It  could  not  be  produced  by  simple 
overfeeding  with  fat.  Its  exact  cause  is  as  yet  unknown,  but 
recent  studies  in  the  author's  laboratory  seem  to  point  to  its 
being  related  in  some  way  to  the  condition  of  the  cells  in  the 
pancreas,  and  evidence  is  accumulating  which  indicates  that  there 
may  be  an  internal  secretion  of  that  gland  which  is  directly  con- 
cerned with  the  production  of  lipemia. 

The  second  problem  in  the  role  of  fat  in  diabetes  is  con- 
cerned with  -acidosis.  Before  entering  into  its  discussion,  it  is 
necessary  to  have  a  clear  understanding  of  what  wTas  meant  by 
acidosis.  In  the  author's  opinion  the  term  should  be  restricted 
to  the  original  definition  given  by  Naunyn,  which  stated  that  its  one 
constant  characteristic  was  the  occurrence  in  the  blood  of  an  ab- 
normal amount  of  beta-oxybutyric  acid  and  acetone  bodies.  Con- 
trary to  the  present  misuse  of  the  term  it  had  nothing  to  do 
with  a  simple  displacement  of  the  reaction  of  the  blood,  and  con- 
ditions with  diminished  alkalinity,  increased  carbon  dioxide  ten- 
sion, increased  hydrogen-ion  concentration,  and  reduction  of  the 


250  BLOOD    AND   URINE    CHEMISTRY 

"buffer"  salts  should  not  be  classed  as  acidosis,  since  such  a 
classification  led  to  confusion. 

Here,  as  in  lipemia,  the  precise  ultimate  cause  of  acidosis  is  not 
known.  It  was  fairly  certain,  however,  that  fat  played  an  im- 
portant role  in  its  production  and  that  the  acids  were  produced 
largely  in  the  muscles  and  liver — organs  in  which  fat  was  burned. 
It  was  not  yet  known  what  proportion  of  fat  could  be  burned 
without  the  production  of  acidosis  in  subjects  with  diabetes,  or 
what  proportion  of  carbohydrate  was  required  to  prevent  the  de- 
velopment of  acidosis.  It  could  be  stated  positively,  however,  that 
acidosis  was  not  necessarily  due  to  a  lack  of  carbohydrate.  If  it 
was  not  possible  to  state  the  ultimate  causes  of  acidosis  at  least 
the  study  of  the  partially  depancreatized  dogs  had  made  it  pos- 
sible to  gain  an  insight  into  some  of  the  more  remote  causes. 

It  was  found  that  acidosis  could  be  produced  in  such  dogs  in 
three  ways,  all  in  complete  imitation  of  the  conditions  encoun- 
tered in  man.  First,  it  could  be  produced  by  following  the  plan 
adopted  in  the  usual  clinical  treatment  of  human  diabetes,  namely, 
by  giving  a  diet  of  high  caloric  value  and  high  fat  content.  If 
an  experimental  dog  with  diabetes  be  made  to  hold  or  to  gain 
weight — which  is  the  practice  in  man — fat  must  "be  introduced 
into  the  dietary  and  calories  must  be  crowded.  One  of  two  things 
soon  happens  in  the  dog;  either  he  begins  to  vomit  and  suffer 
from  diarrhea  with  loss  of  weight  and  refusal  of  the  food,  or,  if 
the  feeding  is  forcibly  continued,  his  metabolism  breaks  down. 
When  the  latter  occurs  true  acidosis  develops  and  a  fatal  dia- 
betic coma  quite  similar  to  that  in  man  ensues.  Such  a  diabetic 
coma  can  be  produced  in  these  animals  while  they  are  thus  kept 
on  a  full  diet,  and  this  is  just  what  occurs  in  human  beings. 
Secondly,  if  the  treatment  employed  in  moderate  human  cases  be 
applied  to  these  dogs,  the  same  results  will  ensue  as  in  the  first 
case.  This  is  the  fattening  treatment  which  is  marked  by  a  re- 
duction in  the  intake  of  protein  and  the  administration  of  fat. 
These  dogs  look  extremely  well,  but  they  go  on  to  a  fatal  acidosis. 
The  third  way  is  that  in  which  the  animals  are  kept  free  from 
glycosuria  through  the  administration  of  a  diet  very  low  in  car- 
bohydrates and  consisting  mainly  of  fat  and  protein.  This  form 
of  diet  is  also  often  prescribed  for  man. 


ACIDOSIS  251 

In  both  'man  and  in  these  animals  if  the  condition  has  not 
gone  too  far  the  acidosis  may  be  checked  by  the  introduction  of 
a  period  of  fasting,  but  if  the  diet  is  restored,  the  downward 
progress  will  continue.  In  severe  cases — human  or  animal — the 
fasting  may  at  first  increase  the  acidosis,  but  if  the  fasting  is  re- 
peated with  periods  of  return  to  a  properly  adjusted  diet,  it  is 
usually  possible  to  produce  an  immunity  to  the  fasting  acidosis 
and  an  ultimate  recovery  of  very  marked  degree.  These  observa- 
tions, along  with  others,  the  details  of  which  cannot  be  given,  all 
point  to  the  existence  of  some  specific  internal  function  of  the 
pancreas  which  is  concerned  with  the  production  of  acidosis. 
They  also  show  that  an  alteration  in  the  reaction  of  the  blood  is 
not  the  cause  of  death  in  acidosis,  for  the  blood  may  be  kept  nor- 
mal in  reaction  by  the  proper  administration  of  alkalies,  and  yet 
the  man  or  the  animal  may  die  of  diabetic  coma  and  typical 
acidosis. 

If  periods  of  fasting  are  properly  introduced  and  the  diet  is 
adjusted,  it  is  possible  to  keep  the  human  or  animal  patient  in  a 
condition  of  physical  comfort  and  fair  health  for  long  periods 
of  time,  and  ultimately  to  increase  his  tolerance  for  foods  to  a 
great  extent.  It  was  also  pointed  out  that  the  craving  for  car- 
bohydrate seen  in  many  diabetics  was  not  due  to  "original  sin," 
but  was  a  physiological  demand  for  that  food  element  which  does 
the  most  perhaps  to  control  the  development  of  acidosis.  The  same 
craving  was  to  be  observed  in  an  intense  degree  in  the  dogs  suffer- 
ing from  acidosis. 

The  last  point  to  be  discussed  by  Allen  was  the  value  of  fat  in 
the  dietary  of  diabetics,  and  it  was  shown  that  fat  unbalanced  by 
other  food  constituents  was  a  poison.  The  essence  of  these  observa- 
tions was  to  show  that  it  was  necessary  to  preserve  a  natural  bal- 
ance between  fats  on  the  one  hand  and  protein  and  carbohydrate 
on  the  other  if  dangerous  complications  were  to  be  avoided — 
especially  acidosis  and  coma. 

The  net  results  of  the  observations  pointed  to  the  absolute  neces- 
sity for  clearing  up  the  lipemia  of  diabetes ;  to  the  need  of  a  proper 
appreciation  of  the  importance  of  fat,  unbalanced  by  other 
foods,  in  the  production  of  acidosis;  and  finally  to  the  most  im- 
portant fact  of  all,  namely,  that  in  diabetes  there  was  a  deficient 


252  BLOOD    AND    URINE    CHEMISTRY 

assimilative  function  and  that  efforts  to  maintain  the  body  weight 
by  high  calory  feeding  would  soon  lead  to  an  exhaustion  of 
whatever  function  remained  to  the  patient.  The  true  lesson  to 
be  learned  was  that  it  was  not  fat  alone,  not  protein  alone,  and 
not  carbohydrate  alone  which  was  the  source  of  danger,  but  that 
it  was  a  disturbed  balance  between  all  three  combined  with  an 
overtaxing  of  the  patient's  assimilative  powers  which  led  to  the 
downward  progress  of  diabetics  under  the  usual  plans  of  dietetic 
regulation.  Depending  upon  the  severity  of  the  case,  the  load  on 
his  assimilative  function  should  be  lightened ;  if  he  had  acidosis 
he  should  be  starved,  once  or  repeatedly,  until  his  assimilative 
function  could  be  restored ;  and  his  diet  should  be  kept  within 
his  assimilative  capacity.  If  such  a  plan  were  followed,  the  ma- 
jority of  patients  would  live  in  comfort,  and  a  large  proportion 
would  ultimately  show  a  decided  increase  in  the  extent  of  their 
assimilative  capacities. 

In  connection  with  the  blood  chemical  methods  for  estimating 
acidosis  in  nephritis,  the  recent  work  of  Marriott  and  Howland18 
deserves  special  mention.  They  note  that  in  the  terminal  stages  of 
nephritis  there  is  frequently  an  existing  acidosis  as  determined 
by  diminished  carbon  dioxide  tension  of  the  alveolar  air,  and  in- 
creased hydrogen-ion  concentration  of  the  blood  or  serum,  a  dim- 
inution of  the  alkali  reserve  and  of  the  oxygen  combining  power  of 
the  hemoglobin.  They  state  that  this  acidosis  is  not  due  to  an  ac- 
cumulation of  the  acetone  bodies  as  they  do  not  appear  in  the  urine 
and  they  are  not  increased  in  the  blood.  That  it  is  not  due  to  the 
presence  of  lactic  acid  seems  to  be  proved  by  the  work  cf  Lewis, 
Ryffcl  and  others,19  who  showed  that  lactic  acid  is  not  increased  in 
the  blood  in  this  kind  of  acidosis.  Henderson  and  Palmer20  showed 
a  diminished  ammonia  excretion  in  severe  nephritis.  An  expla- 
nation for  this  acidosis  of  severe  nephritis  is  the  fact  that  the  kid- 
neys may  be  failing  to  excrete  the  acid  substances  which  arc  or- 
dinarily formed  there.  The  regulation  of  the  acid  base  equilib- 
rium of  the  body  is  largely  brought  about  by  the  ability  of  the 
kidney  to  excrete  acid  phosphate.  In  order  to  demonstrate 
whether  or  not  this  is  true  and  whether  or  not  in  severe  nephritis 

"Marriott  and   Ilowland:      Arch.   Int.    Med.,   Nov.    13,    1916,   vol.   xviii,   No.    5,   p.   708. 
"Lewis,  RyfTel,  and  others:     Heart,  1913,  vol.  v,  p.  45. 

:°IIenderson  and  Palmer:  Jour.  Uiol.  Chem.,  1915,  vol.  xxi,  p.  37;  Arch.  Int.  Mcd., 
1915,  vol.  xvi,  p.  109. 


ACIDOSIS  253 

there  is  a  consequent  accumulation  of  inorganic  phosphates  in 
the  blood,  Marriott,  Haessler,  and  Rowland21  worked  out  a  sim- 
ple method  to  determine  these  inorganic  phosphates  in  a  small 
quantity  of  serum. 

This  method  is  based  upon  the  fact  that  the  red  color  of  a  solution 
of  ferric  thiocyanate  is  discharged  by  certain  substances,  among 
which  are  oxalates  and  phosphates.  Calcium  is  precipitated  as  the 
oxalate,  dissolved  in  acid,  added  to  a  standard  solution  of  ferric 
thiocyanate  and  made  up  to  a  definite  volume.  The  color  of  the 
resulting  solution  is  compared  with  that  of  a  solution  containing 
known  amounts  of  calcium  oxalate  and  ferric  thiocyanate.  The 
phosphates  are  precipitated  as  a  magnesium  and  ammonium 
phosphate.  The  precipitate  is  dissolved  and  color  comparisons 
are  made  as  above. 

In  a  personal  communication,  Marriott  and  Haessler  give  more 
elaborate  details  on  this  micro-determination  of  inorganic  phos- 
phates in  the  serum,  as  follows: 

"Dilute  1  c.c.  of  clear,  nonhemolyzed  serum  with  5  or  10  c.c. 
of  water.  Add  two  drops  of  N/10  HC1  and  1  c.c.  of  'magnesium 
mixture.'*  Run  in,  drop  by  drop,  with  stirring,  2  c.c.  of  10% 
ammonia  (1  volume  concentrated  ammonia  to  9  of  water) — allow 
to  stand  overnight  at  room  temperature  in  order  to  complete  pre- 
cipitation. Filter  off  precipitate  on  a  10  c.c.  Gooch  crucible,  the 
mat  being  prepared  as  follows:  A  small  disc  of  filter  paper  is 
first  placed  in  the  bottom,  asbestos  soup  is  poured  on  to  make  a 
fairly  thick  mat, — another  disc  of  filter  paper  is  laid  on  and 
then  a  little  more  asbestos,  finally  a  suspension  of  purified  barium 
sulphate  is  poured  on.  This  latter  serves  to  make  evident  any 
leaks  in  the  crucible  and  also  to  close  the  pores. 

"Wash  the  precipitate  four  times,  each  time  with  5  c.c.  of  the 
10%  ammonia, — then  twice  with  10  c.c.  portions  of  95%  alcohol 
and  finally  twice  with  10  c.c.  portions  of  ether.  The  crucible  is 

21Howland,  Haessler,  and  Marriott:     The  Use  of  a  New  Reagent  for  Microcolorimetric 
Analysis  as  Applied  to  the  Determination  of  Calcium  and  of  Inorganic   Phosphates  in  the 
Blood  Serum,  Jour.  Biol.  Chem.,  March,   1916,  proc.  xviii,  vol.  xxiv,  No.  3. 
'Magnesium  mixture  is  prepared  as  follows: 

Magnesium    chloride    sticks,  10  gm. 

Ammonium    chloride,  5  gm. 

Dissolve    in    250    c.c.    of    water    and    add    am- 
monium  hydrate    (cone.),  10  c.c. 

Allow   to  stand   overnight   to  allow   impurities  to  settle.      Filter,   neu- 
tralize with  hydrochloric  acid,  and  make  up   to  500  c.c. 


254  BLOOD    AND    URINE    CHEMISTRY 

put  back  in  the  beaker  and  allowed  to  dry  overnight  at  room 
temperature  or  for  an  hour  in  an  air  bath  at  50°.  The  washing 
with  alcohol  and  ether  is  to  remove  lipoids. 

"Ten  c.c.  of  N/100  HC1  is  run  into  the  crucible  and  the  beaker 
covered  tightly  with  a  piece  of  rubber  tissue  secured  with  a  rub- 
ber band  and  allowed  to  stand  several  hours  to  complete  the  solu- 
tion of  the  precipitate.  The  asbestos  is  then  thoroughly  stirred 
up  in  the  acid  and  the  suspension  poured  off  into  a  small  tube 
and  centrifuged.  An  aliquot  portion  (usually  6  c.c.)  of  the  clear 
supernatant  liquid  is  pipetted  off  and  used  for  the  determination. 

' '  COLORIMETRIC  COMPARISON. — Ammonium  Thiocyanate  Solution 
(3  grams  to  1000  c.c.  ferric  chloride  solution). — Weigh  out  3 
grams  of  ferric  chloride  with  its  contained  water  of  crystalliza- 
tion. Dissolve  in  water  and  add  just  sufficient  HC1  to  make  a 
clear  solution  and  make  up  to  1000  c.c.  Just  before  use,  these 
solutions  are  mixed  by  taking  5  c.c.  each  and  making  up  to  from 
35  to  50  c.c.  with  distilled  water,  this  solution  being  used  more 
dilute  for  serum  containing  small  amounts  of  phosphate.  Ac- 
curately measured  2  c.c.  portions  of  the  iron  thiocyanate  solution 
thus  prepared  are  measured  into  10  c.c.  volumetric  flasks;  the 
aliquot  portions  of  the  phosphate  solution  are  added  in  the  flask 
and  the  liquid  made  up  to  the  mark  with  N/100  HC1.  Known 
amounts  of  a  standard  solution  of  magnesium  ammonium  phos- 
phate in  N/100  HC1  are  added  to  other  10  c.c.  flasks  containing 
thiocyanate  and  made  up  to  the  mark  with  N/100  II Cl.  Color 
comparisons  are  made  in  small  glass  tubes  approximately  120 
mm.  long  by  10  mm.,  internal  diameter.  The  tubes  are  filled  to 
the  same  height  and  compared  by  looking  through  thorn  length- 
wise against  a  white  surface.  The  colors  do  not  change  within 
an  hour's  time. 

"Standard  Magnesium  Ammonium  Phospliatc  Solution. — Dis- 
solve .1584  gm.  of  air  dried  MgNH4Po.t .  GH,0  in  100  c.c.  of  N/10 
hydrochloric  acid  and  dilute  to  1  liter  with  water.  Of  this  solu- 
tion, 1  c.c.  .02  mgm.  phosphorus. 

''Additional  notes  and  cautions  on  the  determinations  of  cal- 
cium and  inorganic  phosphate  are  given  as  follows: 

"CALCIUM  METHOD.— In  the  ashing  of  the  blood  by  nitric  acid 
a  certain  amount  of  difficultly  soluble  calcium  sulphate  is  formed. 


ACIDOSIS  255 

This  is  especially  insoluble  if  the  liquid  is  allowed  to  go  to  dry- 
ness.  In  all  cases,  it  is  advisable  after  the  nitric  acid  has  evap- 
orated to  add  distilled  water  to  the  flask  and  to  heat  on  a  sand 
bath  just  below  boiling  for  one  hour  or  more,  in  order  to  com- 
pletely bring  the  calcium  into  solution. 

"By  '20%'  sodium  acetate  is  meant  20%  of  anhydrous  sodium 
acetate.  If  the  crystalline  salt  is  used  the  solution  should  be 
35%. 

"The  beakers  used  in  the  method  should  be  of  the  tall,  narrow 
type  rather  than  of  the  broad  form  as  in  this  way  the  solution 
of  the  precipitate  seems  to  be  more  complete.  Instead  of  centri- 
fuging  the  asbestos  suspension  before  removing  an  aliquot  por- 
tion, filtration  may  be  resorted  to.  Results  obtained  are  the  same. 

"In  the  colorimetric  comparison  of  calcium  and  of  phosphates, 
instead  of  using  10  c.c.  volumetric  flasks,  it  is  convenient  to  have 
a  set  of  small  flat-bottomed  Nessler  tubes,  approximately  120  mm. 
long,  10  mm.  internal  diameter,  these  tubes  being  of  exactly  the 
same  size  and  with  a  graduation  at  the  10  c.c.  mark.  The  solu- 
tions may  be  made  up  in  these  tubes  and  mixed  by  inverting.  In 
that  way  the  volumetric  flasks  may  be  dispensed  with. 

"PHOSPHATE  METHOD. — In  making  up  the  standard  solutions, 
it  is  to  be  borne  in  mind  that  MgNH4Po4.6H20  loses  water  of 
crystallization  if  heated,  and,  therefore,  must  be  dried  at  room 
temperature.  Commercial  preparations  of  this  salt  are  unreliable. 
It  should  be  prepared  by  precipitation  and  dried  as  directed." 

By  this  method  they  determined  the  inorganic  phosphates  in 
the  serum  of  a  series  of  normal  adults  and  older  children  and 
then  of  patients  with  nephritis,  both  with  and  without  acidosis. 
The  normal  figure  expressed  in  terms  of  phosphorus  varied  from 
1  to  3.5  mgms.  per  100  c.c.  of  blood.  In  the  great  majority  of 
normals  the  amount  was  less  than  2  mgms.  They  also  determined 
the  inorganic  phosphate  in  the  serum  of  patients  with  acidosis 
occurring  in  the  course  of  nephritis  and  in  every  instance  they 
found  an  increase  in  the  phosphorus  to  many  times  the  normal, 
that  is,  an  increase  up  to  23  mgms.  per  100  c.c.  of  blood.  They  be- 
lieve that  the  retention  of  the  acid  phosphate  (for  approximately 
90  per  cent  of  the  phosphate  in  an  average  urine  is  acid  phos- 
phate) would  seem  to  be  sufficient  to  account  for  the  degree  of 


250  BLOOD    AND    URINE    CHEMISTRY 

acidosis  observed.  They  do  not  claim  that  this  is  the  sole  fac- 
tor in  this  acidosis  of  nephritis,  but  they  point  to  the  fact  that  the 
retention  of  acid  phosphate  in  nephritis  is  not  part  of  a  general 
salt  retention;  that  it  seems  to  be  due  to  a  certain  "specificity" 
of  retention  because  there  was  no  corresponding  increase  of  so- 
dium chloride  with  the  increase  in  acid  phosphate.  It  was  not 
proportional  to  the  total  nitrogen  and  the  urea  retention  in 
these  cases.  In  other  words  th^  phosphate  retention  was  not 
a  result  of  the  acidosis  per  se,  for  these  writers  failed  to  find  a 
similar  increase  in  the  inorganic  phosphate  in  that  form  of  acid- 
osis seen  in  diabetics.  They  believe  that  the  phosphate  is  due 
to  some  disturbance  in  the  specific  function  of  the  kidney  and 
not  to  increased  phosphate  production  in  the  body  or  increased 
absorption  from  the  intestinal  canal,  because  the  urinary  output 
of  phosphate  is  not  increased  and  may  even  be  decreased.  They 
failed  to  reduce  this  phosphate  retention  by  the  administration 
of  alkali  and  even  demonstrated  an  increase  of  the  substance 
under  sodium  bicarbonate  administration. 

They  also  found  in  these  cases  a  marked  reduction  in  the  cal- 
cium of  the  serum,  in  one  case  as  low  as  1.5  mgms.  per  100  c.c. 
of  serum  as  compared  wTith  the  normal  of  10  to  11  mgms.  The 
low  calcium  is  to  be  referred  to  an  excess  of  phosphates  in  the 
serum,  as  already  detailed.  The  administration  of  phosphates 
causes  an  increased  elimination  of  calcium  through  the  feces,  and 
the  converse  is  also  true;  the  administration  of  calcium  leads  to 
an  increased  elimination  of  phosphate,  also  by  the  intestines. 
This  fact,  according  to  these  investigators,  may  offer  a  suggestion 
for  rational  therapeutic  procedure. 

At  the  May,  1916,  meeting  of  the  Association  of  American  Phy- 
sicians, a  very  excellent  summing  up  of  the  entire  question  of 
acidosis  was  gone  into  by  the  leaders  on  this  question ;  namely,  L. 
J.  Henderson,  of  Boston,  John  Howland,  of  Baltimore,  R.  T. 
Woodyatt,  of  Chicago,  C.  Frothingham,  of  Boston,  L.  G.  Rown- 
tree,  of  Minneapolis,  Yandcll  Henderson,  of  New  Haven,  and 
Donald  Van  Slyke,  of  New  York.  It  recapitulates  most  of  what  we 
have  discussed,  so  we  will  abstract  it  here.  In  this  symposium  on 
acidosis,22  L.  J.  Henderson,  speaking  on  the  subject  of  the  biochcm- 

22New  York  Med.  Jour.,  Dec.  2,  1916,  p.   1119. 


ACIDOSIS  257 

istry  of  acidosis,  said  that  like  heat  equilibrium,  the  equilibrium  be- 
tween acids  and  bases  was  essential  to  life.  Fluctuations  in  equilib- 
rium occurred,  but  normally  the  limits  of  fluctuation  were  narrow. 
Wider  fluctuations  occurred  pathologically,  but  the  acid  base  fluc- 
tuations did  not  as  a  rule  involve  changes  in  the  hydrogen-ion 
concentration.  Acidosis  was  denned  as  any  disturbance  of  the 
acid-basic  equilibrium  whereby  the  power  to  resist  acids  in  the 
body  was  lost.  It  is  now  possible  to  say  that  the  main  change  in 
acidosis  is  the  loss  of  blood  bicarbonates.  The  bicarbonates  were 
to  be  regarded  as  the  third  constituent  of  the  blood ;  reckoning 
water  first,  salt  second,  and  bicarbonate  third.  This  third  con- 
stituent is  specially  subject  to  fluctuations,  owing  to  the  constant 
physicochemical  interchanges  between  blood  and  respired  air;  and 
since  hydrogen-ion  concentration  is  proportional  to  the  reactions 
between  bicarbonates  and  free  carbon  dioxide,  the  ratio  of  free 
carbon  dioxide  and  bicarbonates  is  kept  fairly  constant  by  the 
mechanism  of  ventilation;  hence,  hydrogen-ion  concentration  is 
now  regarded  as  the  hormone  of  respiration.  The  maintenance 
of  the  acid  basic  equilibrium  becomes  more  complicated  in  patho- 
logical states,  and  is  always  related  to,  and  dependent  on  the  gen- 
eral metabolism  of  the  body.  Beneath  all  metabolism  is  a  constant 
diminution  of  blood  carbonates;  unless  repaired,  this  leads  to 
acidosis.  The  carbon  dioxide  tension  of  alveolar  air  and  of  the 
blood,  together  with  the  measure  of  alkali  ingestion  are  the  meas- 
ures of  acidosis.  Neither  ammonia  concentration  nor  urinary 
findings  are  safe  guides.  Attempts  to  explain  general  pathological 
states  on  the  basis  of  hydrogen-ion  concentration  or  acidosis  are 
not  justified.  Any  attempt  to  treat  a  disease  like  nephritis  by  the 
indiscriminate  administration  of  large  amounts  of  alkali  is  mal- 
practice. Small  amounts  of  alkali,  given  over  a  long  time,  are 
allowable,  and  when  so  given,  acidosis  is  impossible. 

Howland,  speaking  on  "Acidosis  in  Infants  and  Children,"  re- 
peated some  of  the  facts  already  credited  to  him  in  the  preceding 
pages.  He  noted  that  acidosis  in  children  is  a  dangerous,  but 
not  often,  an  acute,  self-limited  disease.  It  is  not  merely  an 
acetonuria,  but  is  dependent  upon  a  loss  of  the  acid  basic  equilib- 
rium of  the  blood.  Hypcrpnea,  as  noted  before,  is  the  clinical 
sign;  laboratory  tests  are  the  indices,  these  being  carbon  dioxide 
tension  of  alveolar  air,  hydrogen-ion  concentration  of  blood,  and 


258  BLOOD    AND    URINE    CHEMISTRY 

alkali  reserve  of  blood.  The  natural  low  level  of  carbon  dioxide 
tension  and  low  hydrogen-ion  concentration  in  the  young  ex- 
plains the  susceptibility  to  acidosis.  Onset  of  acidosis  is  marked 
by  hyperpnea;  coma  soon  ensues;  the  alkali  reserve  might  be  re- 
stored, but  unless  this  occurs  quickly,  death  follows.  When  acid 
phosphates  are  found  in  excess  (five  to  fifteen  times  the  normal) 
in  the  blood,  and  this  condition  continued  long  enough,  it  robs 
the  body  of  its  bases.  Restoration  of  bases  does  not  always  stop 
the  accumulation  of  acid  phosphates.  Acidosis  is  seen  in  many 
diseases  of  infancy  and  childhood  and  should  always  be  kept  in 
mind;  its  early,  rational  treatment  may  be  the  means  of  saving 
life. 

The  next  paper  in  the  symposium  was  that  of  R.  T.  Woodyatt  on 
"Acidosis  in  Diabetes."  He  explained  that  the  occurrence  of 
acidosis  in  diabetes  depended  on  the  definition  of  the  difference 
between  the  diabetic  and  the  normal  individual.  The  proportional- 
ity between  glucose  utilization  and  wastage  depended  upon  the 
rate  of  intake.  It  may  be  said  that  with  a  rate  of  glucose  in- 
take high  enough,  the  normal  subject  became  diabetic;  with  the 
intake  low  enough,  the  diabetic  acts  like  the  normal  individual. 
The  difference  was  in  the  wastage.  The  occurrence  of  acidosis 
in  diabetes  depends  upon  this ;  for  it  has  been  found  that  one 
molecule  of  carbohydrate  must  be  burnt  to  care  for  three  mole- 
cules of  higher  fatty  acids;  if  this  ratio  can  be  maintained,  the 
body  "smoked"  with  unburnt  fats,  acetone,  beta-oxybutyric  acid 
and  diacetic  acid  appear  in  the  urine.  In  diabetics  the  absolute 
rate  of  carbohydrate  utilization  is  low  and  it  is  necessary  to  bend 
down  the  rates  of  protein  and  fat  metabolism  to  meet  that  of  the 
carbohydrates.  Thus  the  application  of  rest,  warmth  and  fasting 
in  diabetes  is  rational.  Acidosis  in  diabetes  may  be  accounted  for 
always  in  the  way  described,  except  in  certain  cases ;  e.g.,  its  occur- 
rence in  the  course  of  septic  processes;  such  may  be  called  ac- 
cidental rather  than  diabetic  acidoses. 

Referring  to  ' '  Acidosis  in  Acute  and  Chronic  Diseases, ' '  Froth- 
ingham  said  that  the  finding  of  acidosis  in  diseased  states  other 
than  diabetes  led  to  a  study  of  carbon  dioxide  tension  of  alveolar 
air,  hydrogen-ion  concentration  in  blood,  acetone  and  ammonia 


ACIDOSIS  259 

nitrogen  output  in  urine,  and  soda  utilization  in  a  large  and  di- 
versified series  of  cases. 

The  very  key-note  of  the  discussion  on  acidosis  was  furnished 
by  Dr.  Yandell  Henderson,  who  emphasized  the  fact  that  in  a 
discussion  on  acidosis,  one  writer  speaks  about  one  thing  and  an- 
other about  an  entirely  different  aspect  of  the  question.  There  is 
need  here,  as  in  other  medical  discussions,  of  a  clear  cut  nomencla- 
ture. It  goes  without  saying  that  the  acidosis  of  former  days  is 
not  the  acidosis  of  today.  The  acidosis  of  nephritis  is  not  the 
acidosis  of  diabetes.  Henderson  urged  that  it  might  be  better 
to  speak  in  one  case  of  a  ketonuria  and  in  another  of  low  carbon 
dioxide  states,  and  so  on.  In  1911  he  was  a  member  of  Haldane's 
Pike's  Peak  expedition,  and  all  of  the  party  had  acidosis  when 
a  sufficient  altitude  was  reached,  if  the  carbon  dioxide  tension  was 
taken  as  an  index.  Henderson  was  very  skeptical  of  the  hurtful 
effects  of  acidosis,  for  he  had  seen  no  figures  which  indicated  a 
more  severe  acidosis  than  he  persistently  had  himself  on  Pike's 
Peak  when  feeling  particularly  well.  The  description  given  by 
Dr.  Lawrence  Henderson  was  on  the  basis  of  sea  level  data.  But 
on  going  above  sea  level  acidosis  increased  with  the  altitude;  in  a 
caisson,  acidosis  diminished.  Miss  Fitzgerald,  of  the  Haldane 
expedition,  had  shown  this  as  a  result  of  hundreds  of  observa- 
tions made  by  her  at  various  altitudes.  The  net  result  of  her 
work  was  that  one  could  determine  the  altitude  of  any  commun- 
ity by  the  measure  of  the  carbon  dioxide  tension  of  the  alveolar 
air  of  the  inhabitants,  or  in  other  words,  by  their  acidosis.  It 
seemed,  therefore,  to  Henderson,  much  safer  to  keep  in  mind  the 
facts;  from  the  urinary  standpoint,  acetonuria  may  be  found; 
from  the  respiratory  standpoint,  variations  in  carbon  dioxide  ten- 
sion, or  volume  of  ventilation  might  be  measured;  from  the  point 
of  view  of  the  blood,  disturbances  of  hydrogen-ion  concentration 
might  be  noted;  and  other  measures  of  the  body's  alkali  acid  bal- 
ance might  be  made.  But  if  all  these  measures  were  to  be  aocepted 
as  measures  of  acidosis,  conditions  of  acidosis  would  be  met  with 
in  which  the  acidosis  was  not  a  condition  of  acid  blood  at  all, 
because  the  hydrogen-ion  concentration  of  the  blood  might  still 
be  normal.  It  is  therefore  necessary  to  formulate  and  keep  clear- 
ly in  mind  just  what  in  the  future  is  to  be  known  as  acidosis. 

Van  Slyke,  concluding  this  very  interesting  discussion  on  acid- 


260  BLOOD   AND    URINE    CHEMISTRY 

osis,  called  attention  to  the  fact  that  he  and  his  co-workers  had  been 
much  interested  in  the  relations  between  the  kidney,  lung,  and 
blood  functions  in  acidosis  and  their  observations  had  led  them 
to  conclude  that  the  phenomena  arising  in  the  various  systems 
were  the  corollaries  one  to  another.  He  had  been  struck  by  the 
beautiful  concord  between  the  clinical  and  the  chemical  facts,  and 
the  theoretical  considerations  advanced  originally  by  Lawrence 
Henderson.  Van  Slyke  thought  that  acidosis  was  a  loss  of  the 
normal  relationship  between  acids  and  the  bicarbonates  of  the 
blood.  He  also  believed  in  Rowntree's  classification  of  compen- 
sated acidosis  and  true  acidosis  on  the  basis  of  undisturbed  hydro- 
gen-ion concentration  respectively.  He  believed  that  the  reduc- 
tion of  carbon  dioxide  tension  of  alveolar  air  is  only  an  indirect 
measure  of  hydrogen-ion  concentration  of  the  blood  and  cannot 
be  regarded  as  synonymous  with  acidosis.  It  is  an  exact  measure 
of  the  hydrogen-ion  state  of  the  blood  only  when  the  lungs  are 
functioning  normally  and  under  fixed  conditions  of  temperature 
and  atmosphere.  The  same  may  be  said  of  the  urinary  findings: 
certain  urinary  changes  are  recognizable  and  acceptable  as  indi- 
rect evidences  of  acidosis:  but  they  are  not  synonymous  with 
acidosis,  and  depend  upon  renal  integrity  and  other  factors  for 
constancy. 

To  sum  up  the  theories  of  acidosis,  the  most  essential  elements 
might  be  considered  as  follows:  (1)  the  mixture  of  salts  in  the 
blood  and  body  as  a  whole,  of  which  the  most  important  are  the 
phosphates  and  the  carbonates  and  dissolved  carbon  dioxide 
which  mixture  shows  (2)  a  very  high  resistance  to  change  of 
reaction,  its  so-called  "buffer- value";  (3)  the  action  of  the  car- 
bon dioxide  as  the  easily  variable  factor  in  the  complex,  at  the 
same  time  activating  and  being  itself  regulated  by  the  respiratory 
center ;  (4)  the  strict  proportion  always  found  between  the  various 
radicals  in  this  complex,  and  hence  the  propriety  of  measuring 
the  total  carbonates  in  the  blood  as  a  substitute  for  the  alveolar 
carbon  dioxide;  (5)  the  inverse  relationship  between  alveolar  car- 
bon dioxide,  hence  total  carbonates,  and  the  degree  of  acidosis. 
Whitney23  well  puts  it :  the  production  of  acidosis  entails  two  fac- 


^Whitney,  J.  I,.:     Arch.  Int.  Med.,   1917,  vol.  vi,  p.  931. 


ACIDOSIS  261 

tors  of  importance — (a)  the  rate  of  appearance  of  acid  ions  in 
the  body  and  (b)  their  rate  of  elimination.  The  latter  is  again 
dependent  on  (a)  factors  of  kidney  sufficiency,  (b)  other  methods 
of  elimination  as  by  bowel,  sweat  glands,  etc.,  and  probably  (c) 
certain  factors  having  to  do  with  the  affinity  of  the  tissues,  in- 
cluding the  blood  itself,  for  the  various  radicals.  Whitney's 
work  on  acidosis  in  relationship  to  the  cause  of  death,  with  re- 
marks on  the  acidosis  of  nephritis,  is  a  very  important  contri- 
bution to  the  literature  of  this  question.  Samples  of  blood  were 
taken  by  heart  puncture  as  soon  after  life  was  extinct  as  pos- 
sible. The  Van  Slyke  method  and  later  the  calculation  of  non- 
protein  nitrogen  and  urea  were  made.  Out  of  forty  cases  dying 
of  different  diseases,  all  except  three  showed  a  more  or  less 
marked  acidosis  at  the  time  of  death.  In  many  of  these  cases 
the  acidosis  was  so  severe  that  this  alone  could  have  led  to  re- 
spiratory paralysis,  and  therefore,  this  factor  of  acidosis  may  be 
said  to  be  the  immediate  cause  of  death  in  these  cases.  In  other 
cases  the  acidosis  while  present,  was  not  sufficient  to  be  taken 
into  account  as  the  immediate  cause  of  death,  which  was  probably 
due  to  some  other  toxic  influence.  Infection  seemed  to  have  a 
very  marked  influence  in  causing  acidosis.  All  but  one  case  in 
Whitney's  series  showing  acidosis  had  evidence  of  severe  in- 
fection. The  cases  which  did  not  have  infection  did  not  have 
acidosis.  A  patient  may,  however,  have  marked  infection  with 
intoxication  and  show  no  acidosis,  provided  his  powers  of  elimina- 
tion are  active.  Two  cases  of  death  due  to  circulatory  failure 
showed  no  acidosis.  Two  cases  of  pyloric  stenosis  with  tetany 
showed  alkalosis  as  well  as  a  very  high  incoagulable  nitrogen, 
indicating  a  severe  intoxication.  Whitney  found  that  in  certain 
obscure  toxemias  such  as  intestinal  obstruction,  malignant  tumors 
and  pernicious  anemia,  there  was  no  accompanying  acidosis.  Cer- 
tain heart  cases,  though  severe,  showed  a  lack  of  acidosis,  but 
usually  showed  it  at  the  time  of  death.  As  a  result  of  a  study 
of  a  series  of  nephritics,  Whitney  believed  that  there  are  two 
factors  necessary  to  produce  acidosis:  failure  of  the  power  of 
elimination  and  an  increase  in  the  production  of  acid  in  the  body. 
Cases  with  two-hour  phenolsulphonephthalein  output  over  30  per 


262  BLOOD    AND   URINE    CHEMISTRY 

cent  showed  acidosis  only  if  there  is  a  severe  toxemia,  while  those 
below  30  per  cent  usually  showed  acidosis.  As  causes  of  increased 
acid  production  in  nephritis,  the  toxemia  of  the  active  parenchym- 
atous  form  is  itself  operative;  infection  is  an  even  more  pow- 
erful factor. 


CHAPTER  XXIX 
BLOOD  CHANGES  IN  GOUT. 

Among  other  conditions  in  which  blood  chemistry  has  played 
a  role  in  differential  diagnosis,  might  be  mentioned  gout  and 
rheumatism.  This  disease  which  was  most  accurately  described 
by  Sydenham  (London,  1763)  is  a  peculiar  condition  about  the 
etiology  of  which  there  still  prevails  much  confusion.  However, 
it  may  perhaps  conservatively  be  stated  at  this  time  that  it  is  a 
chronic  disorder  of  metabolism  in  which  there  is  an  undue  ac- 
cumulation of  uric  acid  in  the  blood  as  a  result  of  a  disturbance 
in  the  endogenous  and  the  exogenous  uric  acid  formation.  Gar- 
rod1  as  long  ago  as  1848  contended  that  in  gout  we  have  an  excess 
of  uric  acid  in  the  blood  due  to  increased  formation  and  decreased 
elimination.  Present-day  methods  of  blood  chemical  analyses 
seem  to  prove  that  he  was  correct  in  his  views,  i.  e.,  that  in  gout 
we  have  an  undue  accumulation  of  uric  acid  over  the  normal 
figure  (1-3.0  mgms.  per  100  c.c.  of  blood),  whereas  in  rheumatism 
there  is  no  such  accumulation,  the  figure  remaining  around  1  to 
3.0  mgms.  Without  going  too  deeply  into  the  theories  on  the 
cause  of  this  disturbance  of  metabolism,  we  might  simply  state 
that  according  to  Brugsch  and  Schittenheim,2  gout  results  from 
metabolic  disturbances  due  to  changes  in  the  conversion  of  the 
purin  bases.  Folin  and  Denis3  showed  that  the  amount  of  uric 
acid  in  the  blood  under  normal  conditions,  using  their  colori- 
metric  methods,  varied  from  0.7  to  3.7  mgms.  per  100  c.c.  of 
blood.  Adler  and  Ragle'*  reported,  in  156  patients,  a  variation 
in  uric  acid  from  0.7  to  4.5  mgms.  per  100  grams  of  blood.  These 
cases  were  taken  at  random  from  hospital  cases  and  included 
conditions  such  as  chronic  interstitial  nephritis  in  which  there 
might  be  expected  some  increase  in  the  normal  amount  of  uric 


JGarrod,   A.   B.:     Med.   Clin.,    1848,  vol.  xxxt,  p.   83;   and  Treatise  on   Gout  and   Rheu- 
latic  Gout,   1876.  ' 

2Brugsch:     Gicht.  Spec.  Path.  u.  Ther.,  1913,  Lieferung,  I-IV,  Wien  u.  Berlin. 
Brugsch  and  Schittenheim:     Gicht.     Jena,   1910. 
3Folin  and  Denis:     Jour.  Biol.  Chem.,  1913,  vol.  xiv,  p.  82. 
<Adler  and  Ragle:     Boston  Med.  and  Surg.  Jour,,  1914,  vol.  clxxi,  p.  769. 

2-63 


264  BLOOD   AND    URINE    CHEMISTRY 

acid.  It  was  formerly  supposed  that  uric  acid  could  not  be  found 
in  the  blood  of  normal  persons  who  were  placed  upon  a  purin- 
free  diet.  Its  constant  appearance  with  the  patient  on  this  diet 
was  regarded  in  the  nature  of  things  as  a  test  meal  method  of 
proving  the  existence  of  gout.  That  this  was  entirely  erroneous 
has  been  proved  time  and  again.  For  instance,  McLester,5  using 
the  method  of  Folin,  found  uric  acid  in  the  blood  of  fifteen  nor- 
mal individuals  who  had  been  on  a  purin-free  diet  for  at  least 
three  days,  in  amounts  varying  from  0.5  to  2.9  mgms.  per  100 
c.c.  of  blood.  Pratt6  showed  the  remarkable  changes  of  uric  acid 
in  gout.  He  reported  in  1913  eleven  cases  of  typical  gout  in 
which  the  uric  acid  in  the  blood  had  been  determined  by  the 
method  of  Folin  and  Denis  in  Folin's  laboratory.  In  a  subsequent 
paper  he  reports7  the  number  of  cases  studied  as  sixteen.  He  in- 
cludes only  cases  in  Avhich  tophi  were  found,  or  in  which  a  his- 
tory of  characteristic  attacks  of  acute  gout  was  obtained  or  in 
which  typical  symptoms  developed  while  under  observation. 
Pratt 's  findings  arc  quite  interesting  and  deserve  special  men- 
tion. The  average  amount  of  uric  acid  irrespective  of  the  diet  or 
the  condition  of  the  patient  at  the  time  of  the  examination  was 
3.7  mgms.  Three  of  the  patients  seen  during  the  attacks  were 
on  an  ordinary  mixed  diet.  They  had  4.5  mgms.,  4.8  mgms.,  and 
5.7  mgms.  of  uric  acid.  In  the  blood  of  two  other  patients  examined 
during  an  attack  while  on  a  purin-free  diet,  the  uric  acid  in  four 
determinations  ranged  from  2.4  to  5.1  mgms.,  with  an  average 
amount  of  3.6  mgms.  None  of  these  patients  were  taking  atophan. 
Seven  patients  were  examined  at  a  time  when  they  were  free 
from  symptoms  of  gout  and  when  they  were  on  a  mixed  diet.  Their 
blood  contained  from  3.1  to  5.5  mgms.  The  average  was  4.3  mgms. 
In  the  blood  of  six  patients  examined  when  they  were  on  a  purin- 
free  diet  and  having  no  acute  symptoms,  Pratt  found  uric  acid 
values  from  1.6  to  7.2  mgms.,  an  average  of  3  mgms.  These  figures 
showed  that  in  the  cases  studied  there  was  more  uric  acid  in  the 
blood  when  on  a  mixed  diet  both  in  the  interval  and  during  attacks 
than  when  on  a  purin-free  diet.  In  all,  twelve  examinations  were 
made  when  a  mixed  diet  was  taken  during  attacks  as  well  as  in 

"McLester:     Arch.  Int.  Med.,  1913,  vol.  xii.  p.  737. 

"Pratt:     Tr.  Am.  Assn.   Physicians,   1913,  vol.   xxviii,   p.   387. 

7Pratt:     Am.   Jour.   Med.    Sc.,    1916,  .vol.   cli,   No.    1,  p.   92. 


BLOOD    CHANGES   IN    GOUT  265 

the  intervals,  and  the  average  amount  of  uric  acid  was  4.3  mgms. 
The  general  conclusion  from  these  figures  is  that  in  gout  there 
is  always  a  hyperuricemia.  Thirty-eight  examinations  made  on 
sixteen  cases  of  gout  showed  an  average  amount  of  uric  acid 
of  3.7  mgms.  per  100  c.c.  of  blood.  It  is  generally  believed  that 
there  is  more  uric  acid  in  the  blood  during  an  acute  attack  than 
in  the  intervals,  but  this  is  not  always  true.  Pratt 's  figures  show, 
and  other  investigators  corroborate  them,  that  while  in  gout  there 
is  a  relatively  large  amount  of  uric  acid,  the  diagnosis  of  gout 
cannot  be  based  absolutely  upon  a  single  blood  test:  there  is  a 
high  concentration  found  at  times  in  other  joint  conditions.  But 
it  must  be  remembered  that  in  gout  the  condition  of  hyperuri- 
cemia is  long-continued,  while  in  the  other  joint  conditions  it  is 
transitory.  The  obvious  procedure,  therefore,  is  to  follow  one 
examination  up  with  others  at  interrupted  intervals  of  time.  For 
instance,  one  of  Pratt 's  cases  of  infectious  arthritis  without  any 
of  the  clinical  features  of  gout,  showed  at  the  time  of  the  first 
examination  7.6  mgms.  of  uric  acid.  Seven  months  later  the 
blood  was  again  analyzed  and  only  0.8  mgms.  found,  although 
the  patient  was  then  on  a  diet  rioh  in  purins.  Other  cases  have 
shown  the  necessity  of  repeated  blood  examinations. 

It  seems  that  there  is  no  relationship  between  the  amount  of 
uric  acid  retained  in  gout  and  the  severity  of  the  disease.  Again, 
the  age  of  the  patient  has  no  bearing  upon  this  question.  Atten- 
tion must  also  be  called  to  the  fact  that  the  retention  of  uric 
acid  is  in  no  way  to  be  determined  by  a  diminution  in  the  output 
of  uric  acid  in  the  urine.  Vogt,8  Reach,9  and  others  have  at- 
tempted to  show  that  in  gout  the  excretion  of  exogenous  purin 
is  diminished.  Magnus-Levy,10  however,  has  disproved  this  com- 
pletely, and  Pratt 's11  figures  show  that  a  marked  increase  and 
retention  of  uric  acid  in  the  blood  may  -result  from  the  ingestion 
of  purin  bases  even  when  no  evidence  of  retention  is  found  on 
examination  of  the  urine.  A  number  of  experimental  tfest  meals 
given  for  the  purpose  of  determination  of  whether  or  not  the  giv- 
ing of  purin-rich  diets  can  increase  the  uric  acid  in  the  blood 
of  healthy  people  shows  that  they  cannot  do  so.  It  has  been 

"Vogt:     Deutsch.  Arch.  f.  klin.  Med.,  1901,  vol.  Ixxi,  p.  21. 
"Pf-ach.     Munchen.  med.  Wchnschr.,   1902,  vol.  xlix,  p.  215. 
"Magnus-Levy:     Deutsch.  med.   Wchnschr.,   1911,  vol.   xxvii,  p.   778. 
"Pratt:     Am.  Jour.  Med.  Sc.,  1916,  vol.  cli,  No.  1,  p.  92. 


266  BLOOD   AND   URINE    CHEMISTRY 

clearly  proved  that  the  uric  acid  derived  from  exogenous  purin 
does  not  accumulate  in  the  blood  unless  there  is  a  disturbance  in 
the  uric  acid  metabolism. 

We  have  abundant  analytical  evidence  to  prove,  therefore,  that 
in  gout  there  is  increase  in  the  uric  acid  concentration  in  blood 
without  any  increase  in  the  other  nonprotein  nitrogenous  constitu- 
ents. Daniels  and  McCrudden  are  two  observers  who  have  reported 
several  cases  of  gout  in  women  without  any  increase  in  uric  acid  in 
the  blood.  No  one  else  has  found  normal  figures.  On  the  con- 
trary, Fine,  who  has  contributed  a  great  deal  to  the  literature 
on  uric  acid  values  in  gout  and  other  conditions,  states  that  he 
has  never  seen  normal  uric  acid  in  blood  in  gout.  It  would  seem 
that  in  the  estimation  of  the  amount  of  uric  acid  in  the  blood  we 
have  an  excellent  method  of  differentiating  gout  from  rheuma- 
tism and  other  joint  affairs.  This  is  clearly  evident.  It  must 
be  remembered,  however,  that  the  increase  in  uric  acid  alone 
without  any  increase  of  urea  nitrogen  and  creatinine,  may  occur 
in  early  chronic  interstitial  nephritis.  In  a  recent  communica- 
tion, entitled:  "The  Relation  of  Gout  to  Nephritis  as  Shown 
by  the  Uric  Acid  in  the  Blood,"  Fine,12  goes  thoroughly  into  this 
question.  He  states  that  while  uric  acid  concentrations  up  to  4 
to  9  mgms.  in  blood  are  found  in  gout,  these  accumulations  are 
not  infallible  signs  of  gout.  Indeed,  Garrod,13  von  Jaksch,14 
and  von  Noorden15  pointed  this  out  in  connection  with  the  reten- 
tion of  uric  acid  as  well  as  urea,  but,  of  course,  their  observations 
were  purely  clinical.  Owing  to  the  fact  that  in  early  interstitial 
nephritis  there  is  only  an  undue  retention  of  uric  acid  in  the  blood, 
it  is  necessary  to  exclude  this  condition  before  adopting  the  diag- 
nosis of  gout.  Fine  states  that  there  may  be  no  undue  accumula- 
tion of  urea  nitrogen  and  creatinine  in  early  interstitial  nephritis, 
uric  acid  values  alone  showing  an  abnormal  figure  over  2.5  mgms. 
He  showed  in  collaboration  with  Myers  and  Lough16  very  plainly 
that  in  early  interstitial  nephritis,  there  is  first  an  accumulation  of 
uric  acid;  secondly  an  accumulation  of  urea,  and,  finally,  an  ac- 


12Fi   e:     Jour.  Am.  Med.  Assn.,  1916,  vol.  Ixvi,  No.  26. 

"Ga  rod,  A.   R:     Med.'  Clin.,   1848,  vol.  xxxi,   p.  83;  and  Treatise  on  Gout  and   Rheu- 
latic  Gout,  1876. 

Jaksch:     Zentralhl.   f.  inn.   Med.,  1896,  vol.  xvii,  p.  545. 

Noorden:      Metabolism   and   Practical    Medicine,    1907,   vol.    iii,   p.    29;    Ibid.,    1914, 
ii,  p.  487. 
I(iMyers,  Fine  and  Lough:     Arch.  Int.  Med.,   1916,  pp.   570-583. 


BLOOD    CHANGES   IN   GOUT  267 

cumulation  of  creatinine  in  the  blood.  This  is  what  these  ob- 
servers term  their  "stair-case"  effect.  Twelve  cases  came  under 
their  observation  in  which  more  than  10  mgms.  of  uric  acid  were 
found  in  the  blood  without  any  gouty  symptoms.  In  one  case 
as  much  as  27  mgms.  were  present.  It  was  also  observed  by  them 
that  higher  uric  acid  values  were  seen  early  in  the  cases  than 
later,  although  during  the  agonal  period  there  was  a  marked 
increase  coincident  with  that  of  creatinine.  Folin  and  Denis17  re- 
marked on  the  fact  that  in  the  severest  cases  of  uremia  there  was 
only  a  slight  increase  in  the  blood  ammonia  and  that  it  was  like- 
wise only  these  cases  in  which  a  marked  retention  of  creatinine 
occurred.  They  concluded  from  this  that  the  human  kidney  re- 
moves the  creatinine  from  the  blood  with  remarkable  ease  and 
certainty.  The  completeness  of  the  creatinine  excretion,  is,  in 
fact,  they  further  state,  exceeded  only  by  the  still  more  complete 
removal  of  the  ammonium  salts. 

Myers,  Fine,  and  Lough18  give  in  tabular  form  some  interesting 
data  showing  in  a  series  of  twenty-six  cases  studied,  a  decided 
increase  in  the  concentration  of  the  uric  acid  alone  without  any 
corresponding  increase  in  urea  nitrogen  or  creatinine.  Some  of 
these  cases  showed  symptoms  which  in  general  are  characteristic 
of  early  interstitial  nephritis.  In  other  cases,  although  the  nephri- 
tis was  not  the  predominant  clinical  condition,  it  would  appear 
that  the  systemic  disturbances  resulting  from,  or  associated  with, 
a  variety  of  conditions,  such  as  tuberculosis,  typhoid  fever,  pneu- 
monia, carcinoma,  cardiac  disorders,  chronic  alcoholism,  etc.,  are 
capable  of  exerting  the  same  influence  upon  the  kidney.  It  is 
not  improbable  that  similar  factors  are  at  work  in  gout  and  the 
apparently  uncomplicated  cases  of  interstitial  nephritis.  These 
investigators  also  showed  in  tabular  form  four  cases  of  diabetes  with 
uric  acid  values  of  10.5,  6.0,  5.0,  and  7.6  mgms.  respectively  where 
there  were  similarly  normal  creatinine  values,  namely,  2.1,  2.0, 
2.3  and  4.7  mgms.,  respectively.  The  last  figure,  of  COUFSC,  is  an 
increase  in  creatinine.  In  this  case  the  patient  entered  the  hos- 
pital in  coma  and  died  several  hours  later;  the  urine  contained 
very  large  amounts  of  albumin,  acetone,  and  diacetic  acid,  and 
many  granular  casts.  These  observers  point  to  the  fact  that  their 


l7Folin  and  Denis:     Jour.   Biol.   Chem.,   1914,  vol.  xvii,  p.  487. 
18Myers,  Fine,  and  Lough:     Arch.  Int.  Med.,  1916,  pp.  570-583. 


268 


BLOOD   AND   URINE    CHEMISTRY 


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BLOOD    CHANGES   IN    GOUT  269 

series  of  thirty  cases  were  apparently  suffering  with  early  inter- 
stitial nephritis,  probably  secondary  in  many  instances  to  other 
systemic  disturbances.  They  believe  that  an  increased  uric  acid 
value  alone  without  any  increase  in  urea  nitrogen  or  creatinine 
might  serve  as  an  aid  to  an  early  diagnosis.  They  also  suggest 
that  a  retention  of  uric  acid  may  be  earlier  evidence  of  renal  im- 
pairment of  an  interstitial  type  than  the  classical  tests  of  albumi- 
nuria  and  cylinduria.  In  Fine's  later  paper,19  he  gives  a  table 
(see  Table  XVII,  page  268)  of  two  groups  of  cases,  the  first  com- 
posed of  five  cases  giving  the  classical  histories  of  gout,  and  the 
second  consisting  of  seven  cases  with  some  evidence  of  incipient 
nephritis,  such  as  slight  albuminuria,  cylinduria  or  diminished 
phenolsulphonephthalein  output.  These  cases  were  given  a  pu- 
rin-free  diet  several  days  before  the  examinations  were  made.  The 
first  two  cases  that  he  calls  attention  to  gave  typical  histories  of 
gout,  but  also  showed  one  or  more  signs  of  nephritis  and  from 
this  standpoint  might  well  have  been  placed  in  the  second  group. 
He  points  to  the  striking  similarity  in  the  blood  pictures  in  the 
two  groups. 

There  is  truly  a  slight  increase  of  urea  nitrogen  and  creatinine 
in  group  2,  but  the  increase  is  negligible.  Fine  states  that  many 
cases  of  gout  have  been  reported20  with  blood  uric  acid  concen- 
trations as  low  or  lower  than  the  lowest  in  the  above  group  2. 
Fine  propounds  the  following  queries  as  a  result  of  these  figures: 
1.  Is  gout  merely  a  stage  in  the  development  of  interstitial  neph- 
ritis, whose  further  progress^  may  be  indefinitely  delayed?  2. 
Is  early  interstitial  nephritis  merely  potential  gout,  in  which  the 
clinical  symptoms  may  or  may  not  be  eventually  in  evidence?  3. 
Is  the  uric  acid  retention  of  gout  due  to  the  specific  condition, 
gout,  or  to  a  complicating  early  interstitial  nephritis? 

McClure  and  Pratt21  have  given  us  some  further  striking  proofs 
of  the  facts  cited  above.  They  studied  gout  from  the  Biological 
chemical  standpoint  along  four  lines: 

1.  A  comparison  of  the  uric  acid  content  of  the  blood  in  the 
gouty  and  in  the  nongouty. 


"Fine:     Jour.  Am.  Med.  Assn.,   1916,  vol.  Ixvi,  No.  26. 

20Folin  and   Denis:     Jour.   Riol.  Chem.,   1913,  vol.  xiv,  p.  40;  and  Arch.  Int.  Med.,   1915 
vol.  xvi,  p.  35. 
^McClure  and   Pratt:     Arch.   Int.   Med.,   1917,  vol.   iv,  p.   481. 


270  BLOOD   AND    URINE    CHEMISTRY 

2.  The  results  obtained  by  the  intravenous  injections  of  uric 
acid  in  the  gouty  and  in  the  nongouty. 

3.  The  comparison  of  the  exogenous  output  of  uric  acid  by  the 
gouty  and  the  nongouty  in  feeding  experiments. 

4.  The  functional  conditions  of  the  kidneys  in  gout.      (This 
study  is  as  yet  uncompleted). 

Using  the  methods  of  Folin  and  Denis  they  studied  the  uric 
acid  content  of  the  gouty  and  the  nongouty  subject.  Their  figures 
substantiated  the  facts  already  cited,  to  wit,  that  on  statistical 
evidence,  the  presence  of  more  than  3  mgm.  of  uric  acid  per 
100  c.c.  of  blood  is  a  symptom  of  gout  and  is  of  especial  im- 
portance when  less  than  50  mgm.  of  nonprotein  nitrogen  is  pres- 
ent. They  call  attention  to  the  fact  that  the  method  of  Folin  and 
Denis  which  we  have  described  in  the  first  part  of  this  work 
has  been  criticized  by  Folin  himself.  Nevertheless  by  its  use 
data  have  been  obtained  which  are  of  clinical  interest  in  relation 
to  gout.  McClure  and  Pratt  found  that  although  in  the  majority 
of  cases  of  gout  there  are  increased  amounts  of  uric  acid  in  the 
blood,  a  large  percentage  do  not  have  markedly  increased  quanti- 
ties of  other  nonprotein  nitrogenous  substances  in  their  blood 
when  on  a  purin-free  diet. 

They  next  studied  the  effects  of  intravenous  injections  of  uric 
acid  on  the  quantities  present  in  the  blood  and  urine  of  these 
subjects.  The  method  of  procedure  was  to  obtain  an  endogenous 
level  of  uric  acid  in  the  urine  after  the  patient  had  been  on  a 
purin-free  diet  after  which  the  injections  of  uric  acid  were  made. 
Samples  of  blood  were  taken  before  the  injection,  four  hours 
afterwards  and  at  twenty-four  hour  intervals.  Estimations  of  the 
urinary  uric  acid  were  made  in  urine  collected  in  several  periods 
during  the  day  of  the  injection  and  thereafter  in  urine  collected 
for  twenty-four  hour  periods.  The  patients  were  placed  on  a  purin- 
free  diet  for  seven  days  before  the  injections.  This  diet  con- 
sisted of  bread,  cauliflower,  potatoes,  rice,  cornflakes,  the  cereal 
preparations  of  wheat,  lettuce,  cabbage,  tapioca,  jelly,  cream,  but- 
ter, cheese,  eggs  and  sugar.  They  injected  0.5  gm.  of  uric  acid 
dissolved  in  30  c.c.  of  distilled  water  with  the  acid  of  1  gm.  of 
piperazine.  In  persons  without  gout  these  injections  showed  that 
the  excretion  of  the  uric  acid  may  occur  at  irregular  intervals ; 


BLOOD    CHANGES   IN    GOUT  271 

that  the  starting  of  the  excretion  usually  varies  from  a  few  hours 
to  twenty-four  hours;  that  the  percentage  excreted  ranges  from 
very  little  to  very  much  and  that  the  duration  of  the  output  of 
uric  acid  is  often  protracted  over  several  days.  Again,  the  quan- 
tities found  in  the  blood  in  these  nongouty  persons  varied  in 
different  cases.  In  one  case  no  increase  followed  the  injection. 
There  was  considerable  fluctuation  in  the  amounts  present  in  this 
particular  case.  An  increase  in  the  blood  uric  acid  was  found 
four  hours  after  the  injection  in  four  cases.  This  increase  disap- 
peared within  the  first  twenty-four  hours  in  two  cases,  but  not 
until  the  second  twenty-four  hours  after  the  injection  in  two 
other  cases.  Definite  time  relations  between  the  disappearance 
of  uric  acid  from  the  blood  and  its  excretion  in  the  urine  can 
not  be  established  for  nongouty  individuals.  So  far  as  the  gouty 
patients  are  concerned  in  regard  to  intravenous  injections  of  uric 
acid,  Umber  and  Retzlaff22  prior  to  this  investigation  had  al- 
ready shown  in  gouty  persons  with  "normal"  kidneys  that  the 
percentages  of  uric  acid  excreted  by  three  of  their  patients  were 
none,  8.6  per  cent  and  24  per  cent  within  one  to.  two  days.  In 
their  fourth  case  of  gout  their  patient  had  "beginning  albumin- 
uria."  In  this  case  23.6  per  cent  of  the  injected  uric  acid  was 
excreted  within  the  first  twenty-four  hours.  Pratt  and  McClure 
gave  four  gouty  subjects  these  injections  of  0.5  gm.  uric  acid. 
One  patient  had  a  severe  type  of  nephritis.  Of  the  others  one 
showed  no  signs  of  nephritis  and  two  such  slight  symptoms  of 
that  disease  that  kidney  lesions  could  not  be  definitely  diagnosed. 
In  one  case,  that  with  nephritis,  44  per  cent  of  the  uric  acid 
injected  was  excreted.  There  were  periods  of  low  and  high  en- 
dogenous uric  acid  excretion  in  two  of  their  cases:  this  observa- 
tion has  likewise  been  made  by  Brugsch  and  Schittenhelm.23 
The  amounts  of  uric  acid  in  the  blood  in  five  nongouty  and  four 
gouty  subjects  showed  a  small  but  definite  increase  four  hours  after 
the  injections  in  eight  of  these  patients.  From  these  findings  it 
would  seem  highly  probable  that  by  the  methods  employed  the  sub- 
stance quantitated  in  the  blood  after  the  intravenous  injections 
was  really  uric  acid.  The  increase  in  blood  uric  acid  resulting 

-Umber  and  Ratzlaff:  Zur  Harnsaure-Retention  bei  Gicht.  Verhandl.  d.  Cong.  f.  inn. 
Med.,  1910,  vol.  xxvii,  p.  436. 

23Brugsch  and  Schittenhelm:  Zur.  Stoffwechselpathologie  der  Gicht.  Ill  Mittheilung. 
Ztschr.  f.  exper.  Path.  u.  Therap.,  1907,  p.  480. 


272  BLOOD   AND   URINE    CHEMISTRY 

after  the  injection  of  uric  acid  disappeared  within  forty-eight 
hours  in  four  nongouty  and  one  of  the  gouty  patients.  In  the 
remaining  three  cases  of  gout  it  persisted  over  forty-eight  hours. 
The  five  nongouty  patients  excreted  from  22  per  cent  to  138 
per  cent  of  the  uric  acid  injected.  Of  the  four  cases  of  gout  the 
one  with  nephritis  put  out  44  per  cent  of  the  uric  acid  injected, 
while  very  little  or  none  was  excreted  by  the  other  three.  These 
findings  show  that  the  failure  to  excrete  a  large  percentage  of 
uric  acid  after  uric  acid  injections  (exogenous  uric  acid)  is  not  a 
pathognomonic  symptom  of  gout,  although  it  would  seem  to  occur 
more  frequently  in  gout  than  in  nongouty  persons. 

McClure  and  Pratt  then  studied  the  amount  of  exogenous  uric 
acid  excretion  after  the  feeding  of  purin  or  nuclein  containing 
substances.  They  fed  sweetbreads  to  a  patient  with  chronic 
arthritis  and  to  two  with  gout.  Previous  workers  have  studied 
the  excretion  of  exogenous  uric  acid  first  as  a  basis  for  theories 
relating  to  the  etiology  of  gout,  and  secondly,  as  an  aid  in  the 
diagnosis  of  that  disease.  It  is  true  that  gouty  subjects  eliminate 
less  exogenous  uric  acid  than  do  normal  persons,  but  it  has  not 
been  definitely  shown  that  this  can  be  made  of  diagnostic  im- 
portance. The  mass  of  literature  "on  this  question  speaks  for  the 
amount  of  controversy  that  has  occurred.  Patients  with  chronic 
arthritis,  with  gout,  and  normal  persons  have  been  fed  by  various 
workers  with  purin  or  nuclein  containing  substances.  These 
observations  have  been  made  by  Minkowski,24  Kruger  and 
Schmid,2r<  Ackroyd,20  Pollak,27  Mendel  and  Lyman,28  Plimmer, 
Dick  and  Lieb,29  Bloch,30  Mallory,31  Morris,32  Hirschstein,33 
Burian  and  Schur,34  Ljungdahl,35  Kaufman  and  Mohr,3G  Weiss,37 
and  Hall.38  It  was  found  that  in  normal  persons  after  feeding 
hypoxanthin  the  percentage  of  purin  nitrogen  excreted  as  uric 


^Afinkowski:      Arch.   f.   oxpcr.   Path.   u.    Pharm.,    1898.  vol.   xli,   p.    375. 

"Kruger  and    Schmid:      Ztschr.    f.    physiol.    Cliem.,    1901-02,   vol.    xxxiv,   p.    5-19. 

=°Ackroyd:     Bull.  Con.  for  Study  of  Special   Diseases,   Edinburgh,   1907,   vol.   ii,  p.    14 

=:Pollak:     Dcutsch.   Arch.   f.   klin.   Med.,   1907,   Ixxxviii,   p.   224. 

2sMendel   and    Lyman:     Jour.    Biol.    Chein.,    1910-11,   vol.   viii,   p.    115. 

2;'Plimmer,    Dick   and    Lieb:      Jour.    Physiol.,    1909-10,    vol.    xxxix,    p.    98. 

30Bloch:      Deutsch.    Arch.   f.   klin.   Med.,    1905,   vol.    Ixxxiii,    p.    499. 

:"Mallory:      Bull.    Com.    for    Study   of    Special    Diseases,    1908-09,    vol.    iii,    p.    17. 

3:Morris:     Bull.  Com.  for  Study  of  Special   Diseases,  Edinburgh,   1910,  vol.  iii,  p.   57. 

33llirschstein:      Ztschr.    f.    exper.    Path.    u.    Therap.,    1907,   vol.    iv,    p.    118. 

"-•Burian   and   Schur:     Arch.   f.    d.   gesamt.   Physiol.,    1900,   vol.   Ixxx,   p.   241. 

3:'Ljungdahl:      Ztschr.    f.    klin.   Med.,    1913,    1914,   vol.    Ixxix,   p.    177. 

""Kaufman   and    Mohr:      Deu'srh.    Arch.    f.   klin.    Med.,    1902,    vol.    Ixxiv,   pp. 

:l:Weiss:      Ztschfr.   f.   klin.   Med.    1908,  Ixvi,   p.   131. 

3sllall:     The  Purin   Bodies  of   Foodstuffs,  Manchester,   1902,  p.   64. 


BLOOD    CHANGES   IN    GOUT  273 

acid  nitrogen  varied  from  21  to  72  per  cent ;  after  feeding  a  nu- 
cleinate  of  nucleic  acid,  from  22  to  52  per  cent;  after  giving 
adenin,  it  was  41  per  cent;  after  feeding  thymus  it  varied  from 
11  to  38  per  cent ;  and  after  beef,  veal  or  ham,  it  was  from  8  to  74 
per  cent.  After  feeding  beef  the  exogenous  uric  acid  varied  from 
8  to  44  per  cent  in  persons  reported  by  Ackroyd  and  Mohr.39 
The  mean  average  of  all  figures  was  38  per  cent.  The  time  re- 
quired for  the  excretion  of  the  exogenous  uric  acid  varied  from 
one  to  nine  days. 

In  gouty  patients  the  percentage  of  purin  base  nitrogen  ex- 
creted as  uric  acid  nitrogen  after  feeding  hypoxanthin,  accord- 
ing to  McClure  and  Pratt 's  experiments,  varied  from  5  to  109 
per  cent;  after  adenin  it  was  40  per  cent;  after  nucleic  acid  it 
ranged  from  3  to  30  per  cent ;  after  sodium  nucleinate  from  none 
to  35  per  cent ;  after  thymus  from  none  to  22  per  cent  and  after 
some  form  of  beef  or  ham  it  varied  from  none  to  106  per  cent. 
The  mean  average  percentage  of  excretion  as  exogenous  uric  acid 
nitrogen  of  all  these  substances  fed  was  20  per  cent.  The  pa- 
tients with  gout  when  fed  on  sweetbreads  excreted  6  per  cent  and 
24  per  cent  of  the  purin  nitrogen  contained  in  the  sweetbreads  in 
the  form  of  uric  acid  nitrogen.  Their  general  conclusions  were 
that  more  than  3  nig.  per  100  c.c.  of  blood,  with  the  patient  on 
a  purin-free  diet,  is  a  symptom  of  gout,  but  is  not  diagnostic  of 
this  disease.  No  relation  exists  between  the  amount  of  uric  acid 
and  of  total  nonprotein  nitrogen  found  in  the  blood  of  gouty 
persons.  They  also  believe  that  a  marked  retention  of  nonprotein 
nitrogen  is  not  frequent  in  gout.  The  excretion  of  exogenous 
uric  acid  by  normal,  by  arthritic  and  by  gouty  persons  varies 
greatly  both  in  amount  and  in  duration.  Finally,  the  retention 
of  exogenous  uric  acid  is  a  symptom  of  questionable  importance 
in  the  diagnosis  of  gout. 

From  these  observations  and  reports  we  can  readily  recommend 
the  advisability  of  blood  chemical  analyses  in  dealing  with  sus- 
pected cases  of  gout,  rheumatic  fever,  and  early  interstitial  neph- 
ritis. No  adequate  comprehension  of  cases  of  this  kind  can  be 
obtained  by  mere  urinary  findings  or  the  best  clinical  symptoms. 

""Kaufman  and  Mohr:     Loc.   cit. 


CHAPTER  XXX 
BLOOD  CHEMISTRY  AND  NEPHRITIS. 

It  has  already  been  noted  that  in  gout  we  have  an  alteration 
in  the  concentration  of  one  of  the  nonprotein  nitrogenous  blood 
constituents;  namely,  uric  acid.  Attention  has  also  been  called  to 
the  fact  that  in  early  interstitial  nephritis  we  have  likewise  only 
an  accumulation  of  uric  acid.  It  will  be  necessary  in  discussing 
the  blood  figures  in  chronic  nephritis,  interstitial  or  parenchyma- 
tous  in  variety,  to  refer  to  some  of  the  facts  of  nitrogenous  metab- 
olism. Nonprotein  blood  constituents  are  urea  nitrogen,  uric 
acid,  creatinine,  creatine,  sugar,  chlorides  in  the  form  of  sodium 
chloride,  and  cholesterol.  The  normal  amounts  of  these  con- 
stituents are  as  follows: 

Nonprotein  nitrogen  25  to  30  mgms.  per  100  c.c.  blood 

Urea  nitrogen  12  "  15        "        "      "      "        " 

Uric  acid  1  "      3.0     "        "      "      "        " 

Creatinine  1  "     2.5     "       "     "     "       " 

Creatine  5  "  10        "        "      "      "        " 
Sugar                                                        0.08-0.12% 

Chlorides   as   sodium  chloride                     0.65% 
Cholesterol                                                    0.15% 

For  purposes  of  comparison  we  refer  to  the  table  showing  val- 
ues in  various  diseases  (Fig.  65 A,  page  276)  in  which  we  tabulate 
the  normal  findings  and  the  changes  met  with  in  the  common  dis- 
eases. We  would  also  refer  the  reader  to  Fig.  65B,  page  277,  show- 
ing nonprotein  nitrogen,  etc.,  in  which  more  elaborate  figures  are 
shown. 

At  this  point  we  wish  to  refer  to  the  significance  of  nonnitrog- 
cnous  metabolism : 

Total  Nitrogen  is  eliminated  in  the  proportion  of  15  grams  per 
diem.  It  leaves  the  body  as  follows : 

Urea   (grains)  25  (12  gm.  N)     or  85% 

Creatinine             1.5  or     5% 

Uric  acid              0.5  or     2% 

Ammonia               0.5  or     4% 

Rest  nitrogen      0.5  or     5% 

274 


BLOOD    CHEMISTRY   AND    NEPHRITIS  275 

Where  does  urea  come  from?  In  digestion  protein  matter  is 
broken  down  into  amino-acids  which  are  picked  up  by  the  blood 
just  as  pieces  of  metal  are  picked  up  by  a  magnet.  Some  of  the 
amino-acids  are  retained  and  others  are  transformed  into  am- 
monia and  eliminated.  The  greater  part  of  the  nitrogen  that  is 
eliminated  is  exogenous  (coming  from  food)  and  its  elimination 
occurs  in  the  form  of  urea.  The  blood  holds  up  the  carbonates 
and  preserves  its  neutrality  by  this  means,  by  eliminating  or  get- 
ting rid  of  the  acids.  The  greater  part  of  the  acids  in  urine  are 
made  up  of  acid  phosphates,  derived  from  the  blood.  When  the 
blood  is  no  longer  able  to  get  rid  of  its  acids,  it  calls  upon  its 
ammonia  for  help.  This  has  already  been  alluded  to  in  the  chap- 
ter on  acidosis  (see  page  237).  The  determining  factor  in  re- 
spect to  nitrogen  in  urine  is  the  neutrality  of  the  blood.  If  you 
administer  enough  alkali,  you  can  cause  the  nitrogen  to  entirely 
disappear.  It  is  a  well-known  fact  that  rabbits  eliminate  no  nitro- 
gen in  their  urine  because  they  live  on  a  diet  that  contains  a  good 
deal  of  carbonates.  Nitrogen  depends  upon  the  hydrogen-ion  con- 
centration of  bodily  tissues. 

The  source  of  creatinine  is  entirely  endogenous.  It  is  con- 
stant day  by  day  in  the  body. 

There  have  been  some  interesting  data  experimentally  obtained 
as  to  the  effect  of  the  administration  of  creatine  and  creatinine 
to  animals.  Folin1  was  the  first  by  means  of  his  colorimetric 
methods  to  show  that  the  quantitative  conversion  of  creatine 
or  creatinine  to  creatine  in  vitro  \vas  far  more  difficult  than  pre- 
vious statements  would  lead  one  to  believe.  He  was  unable  to 
prove  that  feeding  experiments  with  creatine  in  man  were  fol- 
lowed by  conversion  into  creatinine.  Other  experimental  observa- 
tions were  made  by  Klercker,2  Wolf  and  Shaffer,3  Van  Hoogen- 
huyze  and  Verploegh,1*  and  others.  Myers  and  Fine5  conclude 
from  their  experimental  observations  that  the  administration  of 
creatinine  appears  to  exert  a  slight  increase  on  the  muscle  con- 
tent of  creatine.  When  creatinine  was  administered  an  average 
of  80  per  cent  appeared  in  the  urine  but  no  elimination  of  crca- 

rpolin:     Hammarsten's  Festschrift,  1906,  vol.  iii. 

=Klercker:  Beitr.  z.  Phys.  u.  Path.,  1906,  vol.  viii,  p.  59;  Biochem.  Ztschr.,  1907, 
vol.  iii,  p.  45. 

"Wolf  and  Shaffer:     Jour.  Biol.  Chem.,  1908,  vol.  iv,  p.  489. 

4Van   Hoogeiihuyze   and   Yerploesrh:     Ztschr.   f.   |>hys.   Chem.,   1908,  vol.   Ivii,  p.    161. 

5Myers  and  Fine:     Jour.  Biol.  Chem.,  1913,  vol.  xvi,  p.  169. 


276 


BLOOD    AND    URINE    CHEMISTRY 


UO 


=>S 


PICTURES 

HRITIS 


LU 


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9 
in 


O 
O 


MILD 
ABETES 


SEVERE 
DIABETES 


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m 


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Fig.    65-4. 


BLOOD    CHEMISTRY   AND   NEPHRITIS 


277 


S  ^ i 

so! 

Is; 


ii 


Fig.    65B. 


278  BLOOD   AND   URINE    CHEMISTRY 

tine  was  detected.  Folin  and  Denis6  experimentally  failed  to 
show  any  creatinine  formation  from  the  administration  of  crea- 
tine,  although  they  noted  a  slight  accumulation  of  creatinine  in 
the  blood  and  a  slight  diminution  in  the  muscle.  In  a  later  paper 
Myers  and  Fine7  reiterate  their  belief  in  the  uniformity  obtained 
from  the  creatine  content  of  the  muscle  of  certain  animals,  par- 
ticularly the  rabbit,  and  suggest  that  this  might  ultimately  be 
found  to  be  the  underlying  factor  in  the  constancy  in  the  excre- 
tion of  creatinine.  Their  results  have  been  confirmed  by  Dor- 
ner,8  Mellanby,9  Eiesser,10  Palladin  and  Wallenburger,11  and  Bau- 
mann.12 

It  appears  to  be  fairly  well  established,  therefore,  that  creatin- 
ine resides  in  muscle  and  that  it  is  constantly  present  in  blood 
in  about  the  same  quantity  at  all  times  in  health  in  the  adult. 
The  importance  of  creatinine  in  routine  blood  chemical  analysis 
in  connection  with  chronic  nephritis  has  also  been  very  well  estab- 
lished. It  seems  strange  that  for  so  long  a  time  only  estimations 
of  total  nonprotein  nitrogenous  blood  constituents  were  the  or- 
der of  the  day.  At  the  present  time  there  is  no  one  ingredient 
that  is  more  important  to  estimate  than  is  creatinine.  Cases  of 
blood  retention  of  which  uremia  constitutes  the  most  striking 
type,  show  accumulation  of  creatinine  as  well  as  urea  nitrogen  and 
uric  acid. 

Shaffer  has  shown  that  it  is  constant  hour  by  hour.  It  is  not 
materially  increased  by  protein  food  intake.  It  is  always  present 
in  muscle  tissue,  as  shown  by  Shaffer,13  and  Myers  and  Fine.14 
Myers  and  Fine15  believe  that  the  urinary  creatinine  is  originated 
from  muscle  tissue.  These  authorities16  have  published  a  num- 
ber of  observations  on  the  metabolism  of  creatine  and  creatinine. 
Their  paper  on  "The  Presence  of  Creatinine  in  Muscle"  shows 
the  content  of  creatinine  in  fresh  muscle  in  quantities  varying 


6Folin  and  Denis:     Tour.   Biol.   Chem.,   1914,  vol.   xvii,   p.   493. 

TMyers  and   Fine:     Jour.  Biol.  Chem.,   1915,  vol.  xxi,  p.   289. 

*Dorner:     Ztschr.  f.   phys.   Chem..   1907,  vol.   lii,  p.   259. 

'Mellanby:     Jour.   Physlol.,   1907-8,  vol.  xxxvi,  p.  447. 

10Riesser:     Ztschr.  f.  phys.  Chem.,  vol.  Ixxxvi,  p.  444. 

"Palladin  and  Wallenburger:     Compt.  rend.  Soc.  de  biol.,  1915,  vol.  Ixxviii,  p.  111. 

"Baumann:     Jour.  Biol.  Chem.,  1914,  vol.  xvii,  p.   15. 

"Shaffer:     Am.  Jour.   Physiol.,   1908-9,  vol.  xxiii,  p.   4. 

"Myers  and  Fine:     Am.  Tour.  Med.  Sc.,  1910,  vol.  cxxxix.  p.  256. 

15Myers  and  Fine:     Jour.  Biol.   Chem.,  1913,  vol.   xiv,  p.  24. 

"Myers  and  Fine:  Jour  Biol.  Chem.,  1913.  vol.  xv.  p.  304;  Ibid..  1913-14,  vol.  xvi, 
p.  174;  Ibid.,  1914,  vol.  xvii,  p.  65;  Proc.  Soc.  Expcr.  Biol.  and  Mcd.,  1913,  vol.  xi,  p.  15; 
Ibid.,  1915,  vol.  xxi,  No.  2,  p.  383. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  279 

in  the  cases  of  rabbits  from  4.5  to  5.9  mgms.,  5.7  in  human  muscle 
in  leg  amputated  for  sarcoma,  2.6  in  leg  amputated  for  gangrene, 
6.8  in  pectoral  muscle  of  case  of  interstitial  nephritis,  6.8  in  heart 
muscle  from  uremic  case,  18.1  in  psoas  muscle  in  interstitial  neph- 
ritis. They  showed,17  as  did  Shaffer,18  and  Folin  and  Denis,19  that 
the  quantity  of  creatinine  present  in  the  muscle  is  much  greater 
than  that  of  the  blood,  liver  or  any  other  tissue.  The  fact  that 
the  greater  portion  of  the  preformed  creatinine  present  in  the 
body  is  found  in  the  muscle,  strongly  suggests  that  this  is  the 
chief  creatinine-forming  tissue. 

Uric  acid  is  partly  exogenous  and  partly  endogenous;  partly 
from  the  metabolism  of  food  and  partly  from  that  of  our  own  tis- 
sues. This  is  about  half  and  half.  If  liver  is  eaten,  we  can  raise 

HN-<:=O 

NKC       6-NI-K  , 


HN-C=O  HN-C=O        HN-C=O 


Hypoxanthirv.  Xanlkln.  Uric  AciJ. 

the  amount  of  uric  acid  present.  It  comes  from  purin,  then 
changed  to  xanthin,  and  then  to  uric  acid.  It  has  to  be  de-amino- 
ized  before  change  to  xanthin  takes  place.  This. takes  place  by 
hypoxanthin  being  formed  from  adenin,  and  xanthin  is  formed 
from  guanin. 

The  following  graphic  representation  shows  this: 
The  second  part  of  the  process  is  an  oxidation,  i.  e.,  the  con- 
version of  hypoxanthin  into  xanthin  and  this  conversion  into  uric 
acid.     Uric  acid,  therefore,  is  the  chief  end-product  in  man  of 
nucleo-protein  metabolism. 

Uric  acid  is  a  difficult  substance  to  dissolve.    It  is  soluble  1  part 

17Myers  and  Fine:     Tour.  Biol.   Chem.,   1915,  vol.  xxi,  p.  389. 
"Shaffer:     Tour.  Biol.  Chem.,  1910,  vol.  vii,  pp.  23,  30. 
"Folin  and  Denis:     Jour.  Biol.  Chem.,  1914,  vol.  xvii,  p.   501. 


280  BLOOD   AND   URINE    CHEMISTRY 

in  39  of  pure  water.  Urates  are  soluble  in  1  part  in  500  under 
conditions  as  they  exist  in  the  body.  Uric  acid  is  the  most  difficult 
for  the  kidney  to  excrete  of  the  nonprotein  blood  constituents; 
urea  comes  next,  and  creatinine  last.  Expressed  in  other  terms, 
creatinine  is  the  easiest  constituent  for  the  kidneys  to  eliminate, 
urea  is  the  next,  and  uric  acid  is  the  last  to  be  eliminated.  Again, 
urea  exists  in  the  body  in  twenty  times  as  much  concentration  as 
creatinine  and  it  therefore  takes  twenty  times  as  much  work  for 
the  kidney  to  eliminate  its  urea  as  its  creatinine. 

With  these  fundamental  facts  before  us,  let  us  consider  what 
has  been  done  in  the  past  with  respect  to  studying  from  a  diag- 
nostic standpoint  the  character  of  nonprotein  metabolism  in  dis- 
ease. It  might  be  mentioned  in  passing  that  the  estimation  of  the 
kidney  function  has  long  been  considered  a  favorite  method  of  de- 
termination of  metabolic  faults.  For  instance,  the  indigo-car- 
min  test,  the  phlorizin  test  and  cryoscopy  of  blood  and  urine 
each  have  had  their  vogue  and  have  been  practically  abandoned 
because  of  the  meager  information  obtainable  thereby.  Possibly 
Geraghty  and  Rowntree,-0  with  their  phenolsulphoiiephthalein  test, 
did  more  to  advance  the  cause  of  kidney  functional  tests  than 
any  of  their  predecessors.  This  test  of  kidney  function  is  quite 
reliable  but  it  has  its  limitations.  It  is  an  excellent  method  of 
estimating  the  function  of  the  kidney  for  the  moment  but  does 
not  represent  the  condition  of  the  kidneys  so  far  as  retention  of 
objectionable  constituents  is  concerned,  over  a  long  enough 
period  of  time  to  accurately  weigh  bodily  metabolic  changes  in 
nonprotein  nitrogen. 

The  question  of  the  comparative  value  of  the  Geraghty  and 
Rowntree  test  and  the  blood  chemical  analysis  for  nonprotein 
nitrogenous  constituents  was  experimentally  carried  out  by  Froth- 
ingham,  Fitz,  Folin,  and  Denis.21  Rabbits  were  used  and  experi- 
mental nephritis  produced  by  the  injection  of  uranium  nitrate 
(1.25  to  3  mgms.)  subcutaneously.  The  first  series  of  animals 
were  killed  under  anesthesia  by  bleeding  from  the  carotid  ar- 
teries. They  were  killed  on  consecutive  days  from  one  to  ten 
days  after  administration  of  uranium  nitrate.  In  a  second  series 


20Geraghty  and  Rowntree:     Jour.  Pharm.  and  Exper    Therap.,  1910,  vol.  i,  p.  579. 
"Frothingham,  Fitz,  Folin  and  Denis:     Arch.  Int.  Med.,  1913,  vol.  xii,  p.  145. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  281 

of  experiments  the  animals  were  allowed  to  recover,  and  the 
blood  chemical  analyses  and  the  phenolsulphonephthalein  tests  were 
made  periodically.  The  blood  specimens  for  chemical  analyses 
were  taken  from  the  marginal  ear  veins.  The  rabbits  were  kept 
in  cages,  fed  on  carrots  and  hay,  100  grams  of  carrots  per  day, 
with  50  c.c.  of  water  administered  by  means  of  a  stomach  tube 
before  the  injection  of  the  phenolsulphonephthalein  (1  c.c.  con- 
taining 6  mgms.)  into  the  muscles  of  the  thigh.  The  animals 
were  kept  in  a  small  cage  over  a  glass  funnel  to  prevent  loss  of 
urine.  After  70  minutes  the  urine  was  obtained  by  massage. 
The  determination  was  made  according  to  Geraghty  and  Rown- 
tree's  method  (see  page  95).  It  was  seen  that  the  normal  rabbits 
have  about  30  mgms.  of  urea  nitrogen  per  100  c.c.  The  rate  of 
phenolsulphonephthalein  in  excretion  in  normal  rabbits  is  about 
60  per  cent  in  70  minutes. 

These  experimental  observations  on  uranium  nephritic  rabbits 
showed  a  decrease  in  the  excretion  of  phenolsulphonephthalein 
and  a  great  accumulation  of  nonprotein  nitrogenous  constituents. 
The  decrease  in  the  phcnolsulphonephthalein  amounted  to  as  little 
as  a  trace  only.  The  retention  of  nonprotein  nitrogen  amounted  to 
as  much  as  216  mgms.  and  of  ureas  as  much  as  172  mgms.  The 
retention  of  nitrogen  remained  high  even  where  the  phenolsul- 
phonephthalein began  to  improve.  In  general  the  tests  paralleled 
each  other.  In  another  series  of  experiments,  the  blood  was  col- 
lected every  two  or  three  days  from  the  veins.  The  nitrogen 
seemed  to  go  on  being  retained  even  where  the  phenolsulphone- 
phthalein excretion  was  improving.  This  seemed  to  prove  that 
the  nitrogenous  retention  represented  the  difference  between  that 
eliminated  and  that  produced,  whereas  the  phenolsulphonephthal- 
ein is  an  indicator  of  elimination  alone.  This  represents  essen- 
tially the  difference  between  the  two  tests.  The  percentage  of 
phenolsulphonephthalein  excreted  affords  an  index  of  the  kidney 
function  at  the  time  the  test  is  made.  The  result  is  apparently 
not  at  all  influenced  by  the  length  of  time  the  kidney  may  have 
been  in  the  condition  indicated  by  the  test.  In  general  these 
tests  parallel  each  other  as  indicators  of  kidney  function  with  the 
essential  difference,  however,  that  the  amount  of  phenolsulphone- 
phthalein excretion  shows  the  renal  function  for  the  moment.  The 


BLOOD   AND   URINE    CHEMISTRY 

amount  of  nonprotein  nitrogen  and  urea  nitrogen  in  the  blood 
is  rather  a  measure  of  accumulating  difference  between  the  waste 
nitrogen  produced  in  metabolism  and  amount  eliminated  by  the 
kidneys.  The  time  element,  the  duration  of  the  condition,  is 
therefore  an  important  factor  in  weighing  up  to  these  results. 
The  outcome  of  a  case  cannot  be  estimated  nearly  so  well  by 
functional  kidney  tests  as  by  blood  chemical  analyses.  Foster- 
reported  a  case  of  marked  kidney  disease  with  normal  elimination 
of  phenolsulphonephthalein.  If  the  prognosis  had  been  based  upon 
the  phenolsulphonephthalein  output,  this  patient  would  have  re- 
covered, but,  as  a  matter  of  fact,  he  died.  Again,  he  mentions  the 
fact  that  a  low  output  would  not  indicate  a  fatal  termination  in 
cases  of  chronic  nephritis.  In  Foster's  case  with  an  output  of 
28  the  patient  died  within  two  days  in  coma.  It  can  thus  be  seen 
that  a  normal  output  of  phenolsulphonephthalein  does  not  neces- 
sarily indicate  kidney  lack  of  function  insofar  as  nonprotein  ni- 
trogenous retention  is  concerned,  nor  does  a  lower  output  than 
normal  indicate  the  outcome  of  a  case.  It  will  be  seen  later  that 
we  have  in  the  estimation  of  the  creatinine  values  particularly, 
a  very  valuable  means  of  prognosis. 

Assuming,  therefore,  that  the  moment  is  now  at  hand  in  diag- 
nosis, where  we  must  weigh  up  the  character  of  blood  retention  in 
cases  of  nephritis,  it  is  manifest  that  the  blood  chemical  figures 
are  the  most  trustworthy  that  can  be  gathered.  We  have  noted 
already  the  percentage  of  nonprotein  nitrogenous  concentrations 
in  health.  In  degenerative  conditions  of  the  kidney,  these  blood 
constituents  are  markedly  altered.  In  early  interstitial  nephritis, 
we  have  the  beginning  of  retention  in  the  shape  of  an  accumulation 
of  but  one  ingredient,  namely,  uric  acid.  Here  values  may  be  seen 
as  high  as  from  4  to  6  mgms.  per  10  c.c.  of  blood,  as  opposed  to 
the  normal  values  of  1  to  3.0  mgms.  Next  we  have  in  more  ad- 
vanced cases  an  accumulation  of  creatinine  in  the  blood,  the  figure 
2.5  mgms.  representing  the  upper  limit  of  the  normal  and  any 
figure  over  this  constituting  an  abnormality.  This  accumulation 
of  the  three  constituents  in  their  order,  uric  acid  first,  urea  sec- 
ond and  creatinine  third,  represents  the  fact  already  detailed, 
that  uric  acid  is  the  most  difficult  substance  for  the  kidney  to  ex- 


-Fostcr,  N.   B.:     Arch.   Int.   Mcd.,   1913,  vol.   xii,  p.   452. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  283 

crete;  urea  occupying  an  intermediate  position,  while  creatinine 
is  the  easiest.  We  have  alluded  before  to  the  "stair-case"  effect 
of  retention  first  pointed  out  by  Myers  and  Fine.  Chace  and 
Myers23  give  a  tabulated  list  of  cases  showing  this  effect  (see 
Table  XVIII,  page  284. 

It  can  readily  be  seen  from  this  table  that  the  first  accumula- 
tion in  the  blood  when  kidney  function  is  interfered  with  by  be- 
ginning chronic  interstitial  nephritis  is  in  the  uric  acid  values, 
next  there  occurs  an  accumulation  of  urea  as  well  as  uric  acid, 
and  finally,  in  uremic  nephritis  we  have  an  accumulation  of  uric 
acid,  urea  nitrogen,  and  creatinine.  This  seems  particularly  in- 
teresting and  important  in  view  of  the  fact  that  the  urinary 
changes  in  some  of  these  cases  are  exceedingly  scant.  The  find- 
ing of  albumin  and  casts  is  often  made,  but  this  gives  the  clinician 
but  little  information  as  regards  the  true  metabolic  processes 
that  are  going  on  and  the  exact  state  of  kidney  function.  We  can- 
not well  understand  how  a  clinician  can  safely  pass  judgment 
in  a  case  of  chronic  nephritis  without  an  examination  of  the  blood 
for  these  ingredients. 

To  recapitulate,  we  know  that  the  greatest  amount  of  reten- 
tion of  urea,  uric  acid,  and  creatinine  occurs  in  chronic  inter- 
stitial nephritis  particularly  when  uremia  is  at  hand.  A  prog- 
nostic sign  of  no  mean  importance  is  that  first  pointed  out  by 
Myers  and  Lough-4  in  their  paper  on  "Diagnostic  Value  of 
Creatinine  in  the  Blood  in  Nephritis."  They  showed  at  that 
time  (1915)  that  when  creatinine  in  the  blood  appeared  in  the 
concentration  of  5  mgms.  per  100  c.c.  of  blood  and  over,  that 
every  one  of  these  cases  terminated  fatally.  Of  the  eleven  cases 
in  their  series  showing  over  5  mgms.  of  creatinine  per  100  c.c.  of 
blood,  all  terminated  fatally  in  from  a  few  days  to  two  months. 
In  this  group  of  cases  the  phenolsulphonephthalein  output  was 
practically  zero,  with  but  one  exception.  These  cases  of  creatinine 
values  of  5  mgms.  or  above  were:  a  case  of  mercuric  bichloride 
poisoning,  with  creatinine  value  of  33.3  mgms. ;  a  case  of  chronic 
interstitial  nephritis  in  uremia  with  creatinine  of  20.5  mgms. ;  six 
other  cases  of  interstitial  nephritis,  with  creatinine  values  of  20.0, 
16.7,  16.6,  14.7,  11.0  and  5.3  mgms.  respectively;  three  cases  of 

^Chace  and  Myers:     Jour.  Am.  Med.  Assn.,  1916,  vol.  Ixvii,  No.   13,  p.  929. 
"Myers  and  Lough:     Arch.  Int.  Med..   1915.  vol.  xvi,  pp.  536-546. 


284 


BLOOD    AND   URINE    CHEMISTRY 


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BLOOD    CHEMISTRY   AND   NEPHRITIS  285 

chronic  diffuse  nephritis,  with  uremia,  with  creatinine  values  of 
14.7,  7.4,  and  7.0  mgms.  of  creatinine  respectively.  They  have 
three  times  as  many  cases  on  record  in  which  this  fact  was  borne 
out. 

The  prognostic  value  of  the  finding  of  5  mgms.  of  creatinine 
or  over  has  been  confirmed  by  the  writers,  together  with  Schisler, 
in  a  group  of  cases  of  thermic  fever  recently  studied  at  the  St. 
Louis  City  Hospital,  a  full  report  of  which  has  been  pub- 
lished.* Here  we  had  a  set  of  blood  findings  identical  in  all  par- 
ticulars with  those  of  uremia.  We  present  in  Fig.  66  a  tabulated 
picture  of  these  cases,  showing  their  blood  and  urinary  findings. 

We  are  able  to  record  three  cases  of  thermic  fever  in  which  the 
creatinine  values  of  4.8,  5.0,  and  6.1  mgms.  respectively,  pointed 
to  a  fatal  ending,  which  ensued  within  forty-eight  hours  from  the 
time  when  the  record  was  made.  In  the  case  of  0 'Conner,  the 
observation  was  made  on  August  1,  and  the  patient  died  the  same 
day.  He  showed  urea  nitrogen  of  33  mgms.,  uric  acid  13.2, 
creatinine  4.8  (slightly  below  the  fatal  prognostic  point),  and 
blood  sugar  0.15%.  His  urine  analysis  showed  albumin  and 
coarsely  granular  casts.  The  next  case  (Fischer)  ran  rather  a 
long  course  for  a  case  of  thermic  fever  which  was  from  the  out- 
set quite  severe.  This  individual  entered  the  hospital  on  August 
2,  1916,  showing  a  severe  picture,  semiconscious,  rise  in  temper- 
ature to  108°  F.,  delirium.  His  blood  findings  on  the  first  day 
were  urea  nitrogen  32,  uric  acid  8.6,  and  creatinine  4.1  mgms. 
From  day  to  day  he  was  tested  and  showed  at  first  a  slight  decline 
in  his  blood  findings.  On  the  eighth  day  of  his  stay  in  the  hos- 
pital his  creatinine  reached  the  fatal  point  of  5.0  mgms.  He  died 
two  days  later.  Autopsy  on  this  case  showed  simply  cloudy  swell- 
ing of  the  kidneys  and  no  other  gross  changes  anywhere.  It 
might  be  mentioned  that  his  Wassermann  of  blood  and  spinal 
fluid  was  negative.  His  urinary  findings  during  all  this  time 
showed  at  first  a  very  heavy  amount  of  albumin  and  moderate 
number  of  granular  casts.  Towards  the  end  of  life  the  urine 
cleared  up  as  regards  albumin,  but,  on  the  day  before  death,  the 
microscopical  picture  showed  the  fields  actually  crowded  with 
granular  casts.  The  next  two  cases  (Huth  and  Ship)  are  especi- 


*Gradwohl,    R.    P>.    H.,   and    Schisler,    R. :     Am.   Jour.    Med.    Sc.,    September,    1917, 
p.   407. 


286 


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BLOOD    CHEMISTRY    AND   NEPHRITIS  287 

ally  interesting  in  that  the  one  case  (Huth),  with  an  apparently 
hopeless  clinical  symptomatology,  had  a  very  good  blood  picture 
(urea  nitrogen  26,  uric  acid  9.6,  creatinine  3.83  mgms.)  while 
the  other  case  (Ship),  observed  at  the  same  time,  with  a  much 
more  favorable  clinical  picture,  showed  a  very  grave  set  of  blood 
findings;  viz.,  urea  nitrogen  76,  uric  acid  14.8,  and  creatinine  6.1 
mgms.  In  the  Huth  case  an  unfavorable  clinical  prognosis  was 
made,  but  a  good  prognosis  was  issued  after  the  blood  examina- 
tion was  completed.  True  to  the  latter  prediction,  he  promptly 
recovered.  The  second  case  with  a  rather  favorable  clinical  prog- 
nosis was  condemned  by  the  blood  findings  of  creatinine  over  5 
mgms.  True  to  this  prediction,  he  died  on  the  following  morning. 
Both  cases  showed  substantially  the  same  urinary  findings,  thus  il- 
lustrating that  no  prognostic  record  could  accurately  be  made  in 
this  way.  The  last  case  was  observed  and  tested  during  the 
period  of  his  convalescence  and  showed  almost  normal  findings. 
These  cases,  therefore,  served  to  illustrate  the  great  value  of 
blood  chemical  methods  in  first  demonstrating  that  the  condition 
met  with  in  thermic  fever  is  quite  analogous  to  that  seen  in 
uremic  nephritis,  secondly,  in  proving  Myers,  Lough  and  Chace's 
contention  that  the  finding  of  over  5.0  mgms.  of  creatinine  in 
blood  serves  to  indicate  a  fatal  ending  in  any  case.  A  report  of  a 
most  unusual  case  of  chronic  interstitial  nephritis,  with  findings 
in  blood  and  urine  made  by  Halsey,25  serves  as  an  object  lesson 
in  pointing  out  the  value  of  this  type  of  work.  This  patient  was 
well  enough  to  visit  the  observer's  office  with  symptoms  of  a  sub- 
jective nature  so  slight  as  to  be  almost  incompatible  with  the  find- 
ings on  physical  examination  and  blood  analyses  and  subsequent, 
rapid,  fatal  ending.  He  was  on  his  way  to  Florida,  but  stopped 
off  in  New  York  with  but  little  idea  evidently  of  the  seriousness 
of  his  condition.  His  urine  showed  no  albumin  or  casts.  His 
blood  examination  showed  urea  nitrogen  97,  uric  acid  6.6,  creatin- 
ine 17.5,  blood  sugar  0.18  per  cent,  blood  plasma  combining  power 
50.  Because  of  these  desperate  findings  he  was  further  detained 
and  carefully  observed.  After  three  days  of  nitrogen-poor  (diet, 
the  blood  examination  showed  urea  nitrogen  129  mgms.,  uric  acid 
6.3,  creatinine  21.8,  blood  sugar  0.18  per  cent.  His  nitrogen  iri- 

"•I-Ialsey,  R.  H. :     Jour.  Am.  Med.  Assn.,  June  10,  1916,  vol.  Ixvi,  No.  24,  p.  1847. 


288  BLOOD    AND   URINE    CHEMISTRY 

take  was  restricted,  and  seven  days  later  his  findings  were:  urea 
nitrogen  132,  uric  acid  7,  and  creatinine  22.3,  with  an  increase  in 
the  carbon  dioxide  combining  power  of  his  blood  plasma  to  53. 
Four  days  later,  still  on  nitrogen-poor  diet,  he  showed  urea  ni- 
trogen 144,  uric  acid  6.1,  and  creatinine  28.9.  His  carbon  dioxide 
combining  power  was  diminished  to  50.  His  protein  diet  was  here 
increased  owing  to  the  effect  on  the  tissues  of  too  long  an  ab- 
stinence from  nitrogenous  food.  Three  days  later  the  findings 
were  urea  nitrogen  150,  uric  acid  5.6,  creatinine  24.2,  blood  sugar 
0.20  per  cent  and  carbon  dioxide  down  to  33.  Further  blood  ex- 
aminations showed  a  corresponding  rise  in  blood  constituents 
and  death  of  patient  occurred  on  the  twenty-fifth  day  of  his  ob- 
servation. This  patient  showed  physically  a  picture  of  hyper- 
tension with  but  the  slightest  hypertrophy  of  the  heart.  The 
conclusions  of  Halsey  from  this  record  were  very  aptly  stated ; 
i.  e.,  that  with  the  examination  of  the  urine  only,  the  seriousness 
of  the  patient's  condition  would  not  have  been  discovered,  also 
that  while  the  phenolsulphonephthalein  test  was  of  value  in  indi- 
cating the  status  of  the  patient  for  the  moment,  the  amount  of 
urea  and  creatinine,  particularly  the  latter,  gave  the  best  clue 
as  to  the  progress  and  the  prognosis. 

Chace20  gives  another  excellent  reason  for  resorting  to  blood 
chemical  methods  in  clinical  practice  in  his  work  on  "Gastric 
Symptoms  in  Nephritis."  Many  cases  of  unrecognized  nephritis 
have  only  symptoms  of  dyspepsia.  He  has  been  much  impressed 
with  the  number  of  cases  of  latent  nephritis  sent  to  the  hospital 
with  a  diagnosis  of  gastric  ulcer  or  of  toxic  vomiting.  The  more 
common  symptoms  which  patients  of  this  type  display  are 
nausea,  vomiting,  loss  of  appetite,  flatulency,  abdominal  distress, 
usually  without  definite  relationship  to  meals,  and  headaches,  fre- 
quently of  the  migrainous  type.  Owing  to  the  depressed  gastric 
secretion  the  diagnosis  of  asthenic  gastritis  is  occasionally  made. 
On  account  of  the  toxic  character  of  the  vomiting  these  patients 
are  frequently  told  that  they  are  suffering  from  enterogenous 
intoxication.  Chace  gives  the  histories  of  a  number  of  cases  in 
which  the  gastric  symptoms  were  predominant.  Some  of  these 
cases  were  fatal  with  high  creatinin  values.  He  concludes  that 


^Chace:     Am.  Jour.   Mecl.   Sc.,   1917, 


BLOOD    CHEMISTRY    AND   NEPHRITIS  289 

gastric  symptoms  are  among  the  most  common  early  symptoms  of 
nephritis  and  that  cases  with  obscure  gastric  disturbances  call 
for  a  complete  blood  chemical  analysis.  Several  of  his  cases 
demonstrated  that  not  only  was  there  retention  of  the  nonprotein 
nitrogenous  constituents ;  but  that  they  had  also  a  high  creatinine 
content  beyond  the  safety  point,  making  a  fatal  prognosis  pos- 
sible— a  fact  borne  out  by  subsequent  developments.  In  some  of 
the  earlier  cases,  the  only  ingredient  retained  was  uric  acid. 
This,  of  course,  is  in  consonance  with  the  order  of  retention  in 
beginning  nephritis. 

Differentiation  of  Cardiac  from  Renal  Lesions  by  Blood  Chemical 
Methods 

Another  set  of  conditions  in  which  the  blood  chemical  analysis 
should  prove  of  striking  value  to  the  clinician  is  the  group  of 
cases  called  cardio-vascular  with  only  secondary  renal  disturbance. 
Differentiation  of  these  cases  from  cases  of  true  nephritis  with 
secondary  cardiac  and  blood  vessel  change  might  well  be  made 
by  means  of  the  colorimetric  methods.  Through  the  courtesy  of 
Dr.  Edwin  Schisler  of  the  St.  Louis  City  Hospital  Staff,  we  are 
permitted  to  record  some  data  on  this  group  of  cases  (see  Table 
XIX). 

In  a  recent  study  by  one  of  us  (Gradwohl)  and  Powell27  of  the 
St.  Louis  City  Hospital,  we.  took  up  the  question  of  the  exact 
value  of  these  new  microchemical  methods  in  that  grave  class  of 
cases  that  have  been  so  erroneously  called  "cardionephritis," 
which  condition  really  rarely  exists.  Our  discussion  of  this  ques- 
tion before  the  Southern  Medical  Association  was  as  follows : 

"As  a  matter  of  fact,  in  but  rare  instances  one  fails  to  exactly 
differentiate  between  a  case  that  is  primarily  renal  and  is  showing 
secondarily  only  cardiac  symptoms,  and  one  that  is  primarily 
cardiac,  and  is  showing  renal  derangement  only  as  a  result  of 
passive  congestion.  Every  clinician  is  familiar  with  the  picture 
of  the  patient  with  failing  kidneys,  where  there  is  basic  and 
marked  organic  and  functional  change,  with  kidney  block,  with 
pathologic  shedding  of  albumin  and  casts,  with  general  edema, 

_27GradwohI,  R.  B.  H.,  and  Powell,  Carl:     South.  Med.  Jour.,  May,  1918,  xi,  Ko.   5,  p. 


2!)0 


BLOOD    AND    URINE    CHEMISTRY 


with  a  flagging  heart  and  disturbed  blood  pressure.  There  is 
again  the  clinical  picture  of  the  individual  who  has  been  a  beer- 
drinker,  a  syphilitic,  or  hard  worker,  or  all  three  combined,  who 
starts  out  with  cardiac  decompensation,  with  secondary  renal 
changes  and  consequently  with  edema,  and  albumin  and  casts 
in  the  urine.  He  has  dropsy  and  often  general  anasarca.  In 
the  full  bloom  of  both  affections,  it  is  well-nigh  impossible  to 
differentiate  between  the  two  conditions.  Both  kinds  of  cases  are 
grave  cases.  The  renal  case  is  in  uremia ;  the  cardiac  case  is 
decompensating  when  seen  by  the  physician  the  first  time  in  hos- 
pital or  private  practice.  Owing  to  the  assumption  that  we  have 
just  made  of  impossibility  of  differentiation,  these  cases  show  the 
following  composite  symptomatology:  they  may  be  unconscious 
or  semi-conscious.  They  may  have  delirium,  severe  or  moderate. 
They  may  show  dyspnea  or  orthopnea.  Both  may  have  edema 
of  the  lungs.  Both  may  show  edema,  ascites  or  general  anasarca. 
They  may  have  a  history  of  several  weeks  preceding  the  attack 
of  dyspnea  or  shortness  of  breath,  with  swelling  of  the  feet  and 
ankles.  They  may  have  a  cough,  with  an  expectoration  of  bloody, 
frothy  or  watery  material.  The  pulse  may  be  strong  in  either 
case,  or  it  may  be  irregular  and  weak.  There  is  nothing  charac- 
teristic about  the  pulse  in  either  condition.  Physical  examination 
of  the  heart  may  reveal  nothing  which  will  point  to  the  exact 
diagnosis,  as  the  heart  may  be  enlarged  or  displaced  in  either 
condition.  Concerning  cardiac  murmurs,  they  are  at  best  obscure 
and  not  to  be  relied  upon.  The  blood  pressure  in  either  condition 
may  be  the  same. 

"We  are  in  short  confronted  with  a  problem  that  is  as  a  rule 
solved  only  at  the  autopsy  table.  After  a  rather  extended  experi- 
ence with  the  blood  chemical  finding  in  both  primary  cardiac  and 
renal  conditions  in  their  earlier  manifestations,  and  after  having 
been  able  to  check  the  clinical  diagnosis  by  these  so-called  re- 
tention tests,  we  decided  to  try  out  the  methods  in  actual  prac- 
tice, in  the  class  of  severe  cases  that  AVC  have  just  described.  \Vc 
append  the  histories  of  a  few  of  the  typical  cases  that  have  been 
studied,  together  with  the  blood  chemical  findings.  All  the  case 
histories  except  the  last  were  City  Hospital  patients.  The  last 


BLOOD    CHEMISTRY   AND   NEPHRITIS  291 

history  is  a  very  interesting  case  seen  in  consultation  by  one  of 
us  (Gradwohl). 

"The  blood  was  taken  in  the  morning  before  breakfast  when- 
ever possible,  received  into  oxalate  of  potassium,  defibrinated,  and 
examinations  were  made  at  once.  We  used  the  following  meth- 
ods: 

"Method  of  Marshall  for  urea  nitrogen, 

"Method  of  Folin  modified  by  Benedict  for  uric  acid, 

"Method  of  Folin  for  creatmine, 

"Method  of  Benedict  and  Lewis  for  sugar." 

CASE  1. — H.  P.,  white  male  aged  63  years.  Entered  City  Hospital  April 
26,  1917,  complaining  of  shortness  of  breath,  dizziness,  cough,  and  edema  of 
extremities.  Has  pain  in  epigastric  area,  and  stomach  trouble,.  Trouble  began 
about  two  weeks  ago. 

Family  History. — Negative:  personal  history,  gets  intoxicated  often,  other- 
wise negative. 

Examination  showed  a  fairly  well  developed  and  nourished  aged  male. 

Head. — Negative,  teeth  poor. 

Neck. — Pulsating  vessels. 

Thorax. — Symmetrical,  friction  rale  on  left  side  posteriorly  near  inferior 
angle  of  scapula. 

Heart. — Systolic  and  diastolic  heard  at  apex  and  transmitting  to  left  axilla. 
Double  murmurs  at  aortic  area,  vessels  sclerotic. 

Ktomacli. — Liver  enlarged,  otherwise  negative. 

Genitalia. — Eight  sided  hydrocele. 

Extremities. — Edematous. 

Skin.— Dry. 

Blood  Pressure.— S.  210;  D.  100. 

Wassermann  Reaction. —  (4  -)-)      (Blood). 

Blood  Chemical  Analysis. — Urea  nitrogen,  16;  uric  acid,  3.3,  creatinine, 
0.90;  sugar,  0.114. 

Urine. — Amber,  specific  gravity  1,027,  acid,  no  albumin,  casts,  sugar,  etc. 

Diagnosis. — Cardiac   syphilis. 

Treatment. — Two  hundred  sixty-five  c.c.  of  blood  was  taken  from  vein 
(needle),  and  patient  placed  on  specific  treatment. 

Patient's  condition  improved  from  beginning  of  treatment,  and  he  was  dis- 
charged May  24,  1917  in  a  fairly  good  condition. 

CASE  2. — J.  G.  White  male  aged  63,  entered  City  Hospital  April  27,  1917, 
complaining  of  shortness  of  breath,  headache,  dizziness,  cough,  edema  of  ex- 
tremities. 

Examination. — Shows  a  fairly  well  developed,  but  poorly  nournished  adult 
white  male. 

Head. — Negative.  Eyes,  right  pupil  very  irregular,  and  larger  than  left. 
Enrs,  nose,  throat,  negative.  Teeth  poor. 

Neclc. — Shows  pulsating  vessels. 

Tliorax. — Symmetrical.  There  is  dullness,  diminished  breath  sounds,  and 
impaired  tactile  and  vocal  fremitus  at  both  bases  posteriorly.  Compensatory 
breathing  over  rest  of  lung  area. 

Heart. — Greatly  enlarged  to  left  and  downward.     Apex  beat  6th  i.c.s.,  1% 


292  BLOOD   AND    URINE    CHEMISTRY 

in.  to  left  of  midclavicular  line.  Diastolic  murmur  at  apex  and  transmitted 
upward  to  base.  Arteries  sclerotic. 

A  bdomen. — Negative. 

Extremities. — Edematous. 

Eeflexes. — Sluggish,  but  present.    No  abnormal  ones  elicited. 

Genita  lia . — Negative . 

Urine. — Showed  much  albumin  and  some  casts. 

Blood  Pressure. — S.  250;  D.  170. 

Blood  Wassermann. — Negative. 

T-  S. — Found  in  sputum.     Sent  to  Koch's  Hospital  May  6,  1917. 

Family  History. — 

Personal  History. — 

Blood  Chemical  Examination. — Showed  urea  nitrogen  108;  uric  acid,  9.8; 
creatinine,  4.48;  sugar,  0.148. 

Patient  expired  May  11,  1917. 

Diagnosis. — Chronic  interstitial  nephritis. 

CASE  3. — F.  M.  Colored  male  aged  65  years.  Entered  St.  Louis  City  Hos- 
pital Sept.  8,  1917,  conscious  and  rational,  complaining  of  weakness,  shortness 
of  breath,  and  swelling  of  the  entire  body  and  extremities.  Coughs  occasion- 
ally and  expectorates  some  frothy  material.  States  condition  began  six  months 
ago  with  swelling  of  the  ankles. 

Family  History. — Negative. 

Past  History. — Diseases  of  childhood:  malaria  when  a  child.  Gonorrhea 
twice. 

Social  History. — Laborer  (farm  work).  Drinks  no  alcoholics.  Smokes  and 
chews  tobacco.  Appetite  poor:  sleeps  well. 

Physical  Examination. — Patient  fairly  well  developed  and  poorly  nourished 
adult,  colored  male,  weight  140  pounds,  height  5  ft.  6  in.  General  anasarca. 

Head. — Pupils  O.  K.,  react  sluggishly,  arcus  senilis  marked. 

Teeth. — In  poor  condition. 

Neck. — Marked  pulsation  of  vessels. 

Thorax. — Symmetrical,  accessory  muscles  of  respiration  evidently  called  on  ; 
diminished  resonance  over  right  side,  increased  tactile  fremitus  on  right. 
Moist  rales  over  entire  chest  front  and  back.  A  friction  rale  is  present,  on 
left  side,  anteriorly,  near  3rd  i.c.s.  at  border  of  sternum. 

Heart. — Enlarged  to  left  and  downward,  apex  impulse  in  6th  i.c.s.  mid- 
clavicular  line.  Fairly  strong,  but  irregular.  Systolic  murmur  at  apex — 
not  transmitted.  Aortic  roughening?  Pulmonic  second  sound  accentuated. 

Vascular  System. — Pulsation  of  peripheral  vessels,  pulse  equal,  irregular, 
low  tension  and  easily  compressible. 

Abdomen. — Distended  ascites,  liver  slightly  enlarged  upward. 

Extremities. — Edematous.     Knee  jerks  absent.     No  abnormal  reflexes. 

Genitalia. — Edematous. 

Urine. — Shows  albumin,  casts,  and  red  and  white  blood  cells.  Leucocytes, 
8000. 

Blood  Pressure. — S.  135;  D.  95. 

Blood  Chemical  Examination. — Urea  nitrogen,  28 ;  uric  acid,  5.9 ;  creatinine, 
2.15 ;  sugar,  0.09. 

Patient  expired  Sept.  18,  1917,  and  autopsy  showed  mixed  nephritis  with 
marked  cystic  degeneration  of  kidneys.  Arterio  sclerosis,  cardiac  hypertrophy, 
with  no  endocardial  or  valvular  disease,  Edema  and  congestion  of  lungs,  ad- 
hesive, pleurisy  on  left,  anasarca,  aseites,  hydrothorax,  hydropericardium. 

CASE  4.— H.  E.  White  male,  age  55  years,  entered  City  Hospital  April  30, 
1917,  unconscious  and  no  history  obtainable.  Patient  is  a  well-developed  and 
nourished  adult,  unconscious  and  extremely  irritable  and  restless.  Respiration 


BLOOD    CHEMISTRY   AND   NEPHRITIS  293 

labored,  and  air  hunger  evident.  Skin  moist,  and  patient  has  occasional  clonic 
contractions  of  muscles. 

Head. — Pupils  irregular,  but  react  to  light  and  accommodation;  eyes 
markedly  rolled  backward. 

Neck. — Rigid,  and  head  slightly  retracted. 

Chest. — Emphysematous,  moist  rales  over  both  bases. 

Heart. — Enlarged  to  left  and  downward.  Apex  beat  in  6th  i.c.s.  first  sound 
short;  second  accentuated. 

Abdomen,  pendulous,  lax  and  liver  enlarged. 

Genitalia. — Negative. 

Extremities. — Show  increased  muscular  tonus,  and  marked  twitching. 

Reflexes. — Knee  jerk  hyperactive,  clonus  present  on  both  sides.     Normal. 

Lumbar  puncture  showed  bloody  fluid  (contaminated),  no  organisms.  Blood 
and  spinal  Wassermanns  negative. 

Urine  shows  4-|-  albumin  and  many  granular  and  epithelial  casts. 

Slood  Pressure.— S.  220,  D.  110. 

Blood  Chemical  Examination  showed:  Urea  N.  21;  creatinine,  3.68;  sugar 
0.188. 

Patient  died  May  1,  1917. 

Diagnosis. — Uremia,  Chronic  interstitial  nephritis. 

CASE  5. — J.  B.  Colored  male,  aged  56  years,  entered  Hospital  Aug.  2,  1917, 
conscious  and  rational,  complaining  of  shortness  of  breath,  cough,  swelling  of 
body  and  extremities,  palpitation  of  heart  and  dizziness.  This  state  of  affairs 
has  existed  about  six  months. 

Examination  shows  a  well  developed  but  poorly  nourished  adult  colored 
male.  General  anasarca,  especially  noticeable  in  face  and  eye  lids. 

Family  History. — Negative. 

Personal  History. — Negative. 

Physical  Examination. — 

Head. — Flat  and  ill  shaped,  with  tortuous  vessels  in  temples.  Arcus  senilis 
marked.  Pupils  O.  K.  Teeth  in  bad  condition.  Visible  pulsation  marked  in 
neck.  Cervical  glands  enlarged. 

Thorax. — Barrel-shaped  and  rigid.  Bales,  moist  in  character,  over  entire 
chest,  front  and  back.  Symptoms  of  congestion  at  lower  angle  of  right 
scapula. 

Heart. — Enlarged  to  left  and  downward.  Systolic  murmur  at  apex  and 
transmitted  to  axilla. 

Abdomen. — Distended  and  tender.  Ascites  present.  Liver  somewhat  en- 
larged. 

Extremities. — Edematous. 

Reflexes. — Knee  jerks  absent.     No   abnormal   ones  elicited. 

Urine. — Showed  albumin  and  casts. 

Chemical  Examination  of  Blood. — Showed  urea  nitrogen,  18 ;  uric  acid,  7.95 ; 
creatinine,  2.42,  sugar  0.150. 

No  autopsy  was  done. 

CASE  6. — E.  S.  Age  40  years,  white  female,  entered  St.  Louis  City*Hospital 
Aug.  9,  1917,  complaining  of  dyspnea,  ascites  with  pains  in  abdomen,  and 
generalized  edema.  Pain  most  marked  in  epigastrium,  and  patient  expecto- 
rates much  frothy  material.  Trouble  began  fourteen  months  ago  during  preg- 
nancy, and  has  grown  progressively  worse  since. 

Family  History. — Negative. 

Patient  has  had  measles,  mumps,  whooping  cough,  had  eruption  on  body 
nineteen  years  ago.  Menstruation  began  at  12,  regular.  Has  had  five  chil- 
dren, one  miscarriage  at  two  months.  Married  at  nineteen,  one  child  by  first 


294  BLOOD   AND   URINE    CHEMISTRY 

marriage;  married  second  time  at  thirty-one;  four  children,  one  miscarriage. 

Physical  Examination. — 

Head. — Scalp  negative;  face  edematous;  eyes  moderately  prominent  and 
horizontal:  nystagmus  present,  marked  when  rotated  laterally.  Pupils  O.  K. 
Nose  and  ears  negative.  Teeth  poor  and  pyorrhea  alveolaris  present.  Phar- 
ynx, tonsils,  etc.,  negative. 

Ned;. — Edematous.  Thyroid  anterior  and  posterior  cervicals  palpable. 
Marked  pulsations  of  vessels  of  neck. 

Chest. — Walls  edematous  and  respiration  labored.  Large  moist  rales  over 
che?t,  front  and  back. 

Heart. — Enlarged  to  left  and  downward.  Systolic  murmur  loudest  at  base 
and  apex,  but  audible  over  entire  precordia.  Not  audible  in  axilla  or  back. 
Sounds  irregular.  Pulse  irregular,  and  poor  volume. 

Abdomen. — Markedly  distended  with  fluid.     Liver  enlarged  and  tender. 

Extremities. — Edematous  markedly. 

Reflex. — All  sluggish.     No  abnormal  ones  elicited. 

Urine. — Shows  albumin  and  casts  in  abundance. 

Blood  Pressure.— 8.  190;  D.  140. 

Chemical  Examination  of  Blood. — Urea  nitrogen  15;  uric  acid,  2.8;  crca- 
tinine,  0.90;  sugar,  0.'096. 

Patient  is  in  Hospital  at  present  time  in  improved  condition. 

Wassermann  later. 

CASE  7. — F.  W. :  age  56  years,  colored  male,  entered  St.  Louis  City  Hospital 
March  26,  1917,  conscious  and  rational,  complaining  of  having  been  sick  for 
past  two  years,  with  shortness  of  breath,  swelling  of  extremities  and  abdomen, 
cough  and  watery  expectoration,  headache  and  dizziness.  Appetite  good, 
bowels  regular.  Urinates  two  or  three  times  daily,  and  three  or  four  times 
at  night. 

Family  History. — Negative. 

Personal  History. — Usual  diseases  of  childhood.  Smallpox  and  malaria 
twenty  years  ago.  Typhoid  fifty  years  ago.  Rheumatism  in  1891.  Was  in 
hospital  one  year  at  that  time. "  Chancre  fifty  years  ago.  Gonorrhea  thirty 
years  ago. 

Plii/ftical  Examination. — Shows  a  well  developed  and  nourished  adult  male, 
dyspneic  and  cyanotic. 

Head. — Pupils  equal  and  react  to  light;  but  fixed  to  accommodation;  phar- 
ynx congested;  marked  pulsation  of  muscles  of  neck. 

Lungs. — Large,  moist  rrlos  over  entire  chest,  front  and  back.     No  dullness. 

Hcfirt. — Enlarged  to  right  and  downward.  Marked  arrhythmia,  with  extra 
systole.  Impurity  of  first  sound. 

Aldomen. — Liver  enlarged.  Eight  regional  hernia.  Moderate  amount  of 
aHcites  present. 

Gcnitalia. — Negative. 

Extremities. — Edematous.  Knee  jerks  absent.  All  reflexes  sluggish;  no 
abnormal  ones  elicited. 

Urine. — Shows  albumin  and  casts  in  moderate  amounts. 

Blood  Pressure.— &.  120,  D.  70. 

Wassermann. — Negative. 

Chemical  Examination  of  Blood. — Urea  nitrogen  16;  uric  acid,  3.3;  creatin- 
ine.  0.90;  sugar,  0.114. 

Patient  expired  very  suddenly  Aug.  16,  1917. 

Autopsy  showed  chronic  myocarditis,  with  acute  dilatation  and  congestion 
of  liver,  spleen,  kidneys,  etc.,  edema  and  congestion  of  lungs;  hydrothorax ; 
ascites;  edema  of  brain.  Kidneys  in  good  condition. 

CASE  8. — II.  S.,  aged  58  years,  had  been  rejected  in  his  youth  for  army 
service  in  his  native  country  on  account  of  a  congenital  heart  lesion.  This 


BLOOD    CHEMISTRY    AND   NEPHRITIS 


295 


patient  was  a  very  busy  professional  man ;  for  several  years  preceding  his 
breakdown  he  had  a  high  blood  pressure.  He  was  troubled  with  nasal  bleeding 
almost  uncontrollable  at  times.  In  the  early  spring  of  1916  he  had  a  very 
s.-vere  attack  of  epistaxis.  Following  this  he  noted  gradually  increasing 
dyspnea.  In  July,  1916,  during  a  very  hot  spell  he  broke  down  suddenly  with 
those  symptoms;  dropsy  and  edema  of  the  legs  extending  to  the  thighs.  He 
became  delirious  very  suddenly.  He  was  seen  by  several  physicians  at  once. 
H's  urine  showed  albumin  and  casts.  There  seemed  to  be  no  exact  method 
of  determining  whether  this  was  a  primary  renal  or  cardiac  disturbance.  His 
blood  chemical  picture  was  as  follows:  uric  acid,  2.4;  urea  nitrogen,  11; 
c-r-'atinine,  2.0 ;  sugar  0.155.  This  clearly  indicated  no  retention.  Acting 
upon  these  findings,  efforts  were  more  particularly  directed  to  the  cardiac  ap- 
paratus. The  patient  came  out  of  his  attack  very  nicely,  and  is  now  attending 
to  his  work  very  well.  Six  months  after  this  paper  was  published,  this  patient 
succumbed  to  his  cardiac  affection.  No  autopsy  was  possible. 

"Surveying  these  case  histories,  and  looking  back  upon  the 
patients  as  we  saw  them,  it  must  be  confessed  that  in  no  instance 
would  we  have  been  able  to  determine  the  exact  diagnosis  with- 
out the  aid  of  the  blood  chemical  tests.  The  autopsy  records  when 
obtainable  corroborated  in  each  instance  the  blood  chemical  find- 
ings upon  which  the  differential  diagnosis  Avas  made. 

TABLE  XIX 

CARDIAC  CASES 


BLOOD 

URINE 

Case 
No. 

Urea 

N 

Uric 
Acid 

Creat- 
inine 

Sugar 

Albumin 

Sugar 

Casts 

1 

16 

3.3 

0.90 

0.114 

None 

None 

None 

6 

15 

2.8 

0.90 

0.096 

+  +  +  + 

None 

+  + 

7 

16 

3.3 

0.90 

0.114 

+  + 

None 

+  + 

8 

11 

2.4 

2.00 

0.155 

Present 

None 

Present 

RENAL  CASES 


2 

108 

9.8 

4.48 

0.148 

+  +  +  4 

None 

+  +  4-4 

3 

28 

5.9 

2.15 

0.090 

Present 

None 

Present 

4 

21 

3.68 

0.188 

+  +  +  + 

None 

+  +  +  + 

5 

18 

7.9 

2.42 

0.150 

Present 

None 

Present 

*  +  +  +  +  Large  amount 

+  +  Moderate  amount 


"Iii  surveying  these  figures  from  this  table  (Table  XIX),  we 
are  struck  by  the  uniformity  of  all  signs,  and  are  similarly  im- 
pressed by  the  blood  chemical  variations.  Further  comment  than 
this  seems  superfluous, 


296  BLOOD   AND   URINE    CHEMISTRY 

"Attention  must  be  called,  too,  to  the  fact  that  the  treatment 
of  these  two  conditions  is  so  widely  different  that  any  effort  to 
harmonize  them  is  practically  an  admission  on  the  part  of  the 
physician  of  his  inability  to  determine  the  primary  cause  of  the 
trouble.  It  is  to  be  noted  that  the  failure  of  exact  diagnosis 
means  impossibility  of  application  of  the  correct  therapeusis. 
Electric  packs  for  instance  in  cardiac  cases  would  be  harmful. 
Morphine  in  cardiac  conditions  is  necessary,  but  dangerous  in 
nephritic  cases  when  there  is  edema  of  the  lungs.  All  kinds  of 
kidney  stimulants  are  dangerous  in  renal  conditions,  but  are  ex- 
tremely helpful  in  cardiac  conditions  in  relieving  the  edema. 
These  are  the  cardinal  points  upon  which  revolve  possibly  the 
question  of  bringing  the  patient  out  of  his  cardiac  or  renal  em- 
barrassed condition,  as  the  case  may  be.  We  offer  these  facts 
as  arguments  for  the  usage  of  blood  chemical  methods  in  this 
group  of  cases.  We  are  confident  that  if  these  methods  are 
properly  performed,  that  the  misleading  and  erroneous  term 
"cardio-nephritis"  will  be  consigned  to  the  limbo  of  "shotgun" 
diagnoses,  where  "malaria,"  "neurasthenia,"  "inflammation  of 
the  bowrels,"  and  others  have  been  long  ago  properly  buried.  In 
addition  to  this,  proper  treatment  may  be  applied,  and  many  of 
these  individuals'  lives  may  be  tided  over  for  considerable  lengths 
of  time." 

It  will  therefore  be  readily  seen  that  in  these  cases  which 
showed  the  symptomatology  of  mixed  cardiac  and  renal  disease, 
there  was  little  if  any  retention  of  the  nonprotein  nitrogenous 
ingredients  in  blood.  The  importance  of  blood  chemical  analyses 
in  this  variety  of  clinical  condition  can  well  be  appreciated. 

Test  Meal  for  Renal  Function  and  Ambard  Coefficient. 

Besides  the  well  known  phenolsulphonephthaleiii  functional  kid- 
ney test  and  the  estimation  of  urea  nitrogen,  uric  acid,  creatinine, 
and  sugar  in  blood,  there  are  other  measures  of  estimation  of 
bodily  metabolism  as  respect  kidney  function.  A  work  of  this 
kind  would  be  incomplete  if  these  were  omitted.  The  other  two 
methods  which  are  used  for  certain  definite  reasons  are  those 
known  as  the  Ambard  coefficient  of  urea  excretion,  and  the  test 
meal  for  renal  function. 


BLOOD    CHEMISTRY   AND   NEPHRITIS 
TABLE  XX 


297 


UREA  NITROGEN 

URIC  ACID 

CREATININE 

XT 

C            * 

Mgms.  per  100 
c.c.  of  Blood 

Mgms.perlOO 
c.c.  of  Blood 

Mgms.perlOO 
c.c.  of  Blood 

"D" 

7/28/16 

<7 

13 

3.2 

2.7 

"B" 

8/1/16 

o* 

12 

2.8 

2.8 

"S" 

8/2/16 

rf1 

12 

1.0 

2.8 

"M" 

8/10/16 

C? 

12 

2.4 

2.7 

*c?  Male. 

6   Female. 

The  renal  test  meal  and  the  estimation  of  renal  function  by 
this  means  is  exceedingly  simple  in  hospital  practice  but  difficult 
to  carry  out  in  private  practice.  The  urine  is  collected  every 
two  hours  during  the  day,  while  the  patient  is  on  a  full  diet,  and 
a  ten  to  twelve  hour  specimen  is  collected  at  night.  No  food  or 
drink  is  taken  except  at  meal  times.  The  collection  of  the  night 
specimen  is  begun  three  hours  after  the  evening  meal.  A  normal 
test  yields  a  maximum  specific  gravity  of  1018  or  more.  The 
specific  gravity  varies  but  nine  points  or  more  from  the  highest 
to  the  lowest  figure,  and  the  night  urine  is  small  in  amount,  400 
c.c.  or  less  and  of  high  specific  gravity,  1018  or  over.  A  lowering 
of  the  maximum  specific  gravity,  a  fixation  of  the  specific  gravity 
and  a  nocturnal  polyuria  are  the  signs  indicative  of  diminished 
renal  function. 

Mosenthal  and  Lewis28  have  given  us  an  excellent  account  of 
these  two  measures  as  compared  to  the  Geraghty  and  Rowntree 
test  and  the  estimation  of  the  nonprotein  nitrogenous  constituents 
in  blood.  They  insist  upon  regarding  each  one  of  these  measures 
as  particularly  designed  to  cover  certain  characteristics  of  each 
case  and  speak  of  them  seriatim.  Each  has  its  place,  each  its  in- 
dication, and  from  each  valuable  deductions  may  be  drawn.  The 
Ambard  coefficient  of  urea  excretion  expresses  numerically  the 
relation  between  the  concentration  of  urea  in  blood  and  the  rate 
of  excretion  of  urea  in  the  urine.  As  a  result  of  the  study  of 
normal  human  beings,  Ambard29  has  asserted  that  when  the  con- 


-"Mosenthal   and   Lewis:      Jour.    Am.    Med.   Assn.,    Sept.    23,    1916,   vol.    Ixvii,    No.    113, 
3.   933. 

'-'"Ambard :      Physiologic   normale   et   patholpgique   des   reins,    Paris,    1914. 


298  BLOOD   AND   URINE    CHEMISTRY 

centration  of  urea  in  the  urine  is  constant,  the  quantity  of  urea 
excreted  in  the  urine  varies  proportionately  to  the  square  root 
of  the  concentration  of  urea  in  the  blood;  thus: 

Urea  inbtood  _  =  Constant}  or       Urea  in  blood  =  CoMtant 

-^Excretion  per  unit  of  time 

Also,  when  the  concentration  of  urea  in  the  blood  remains  con- 
stant, the  quantity  excreted  in  the  urine  varies  inversely  as  the 
square  root  of  the  concentration  in  the  urine ;  thus : 

Bate  of  excretion  I      ^^/Concentration  II 

Bate  of  excretion  II  /  „ 

^Concentration  I 

Or,  as  expressed  by  Mosenthal  and  Lewis : 
Ur 


In  which  K  =  the  coefficient  of  urea  excretion. 
Ur  =  urea  grams  per  liter  of  blood. 
D  —  urea  grams  excreted  in  urine  in  24  hours. 
C  =  urea  grams  per  liter  of  urine. 
P  =  body  weight  in  kilograms. 
70  =  standard  body  weight  in  kilograms. 
25  =  standard  concentration  of  urea  grams  per  liter  of  urine. 

McLean  and  Selling30  have  controlled  Ambard's  original  method, 
by  using  the  exact  methods  of  Folin,  and  state  that  "Ambard's 
coefficient,  when  computed  from  results  obtained  by  the  accurate 
methods  of  Folin  and  his  collaborators,  varies  in  normal  persons 
only  between  comparatively  narrow  limits,  and  may  be  regarded 
as  constant,"  and  further  "that  ingestion  of  urea  does  not  ma- 
terially alter  the  value  of  Ambard's  coefficient,  provided  sufficient 
time  is  allowed  for  absorption  before  examination  is  made.  The 
normal  coefficient  is  between  0.06  and  0.09,  0.08  being  considered 
the  figure."  Quoting  from  Mosenthal  and  Lewis:31  "When  the 
values  rise  above  0.09,  some  impairment  of  the  power  of  the  kid- 
ney to  excrete  urea  is  indicated.  Inability  of  the  kidney  to  elimi- 
nate urea  in  proportion  to  the  concentration  of  the  blood  urea 


"'iMcU-an    and    Sdling:      Jour.    Hiol.    Chem.,    1914,   vol.   xix,   p.    31. 

"Mosenthal  and  I^ewis:     Jour.   Am.   Med.   Assn.,   Sept.   23,    1916,   vol.   Ixvii,   No.    113. 
p.  933. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  299 

results  in  an  increase  in  proportion  to  the  concentration  of  the 
blood  urea  results  in  an  increase  in  Ambard's  coefficient.  In  a 
normal  individual  it  will  remain  within  the  limits  mentioned,  no 
matter  what  the  height  of  blood  urea;  in  cases  with  impaired 
renal  function,  however,  the  kidney  does  not  answer  the  diuretic 
stimulus  of  the  blood  urea  adequately,  too  little  urea  is  put  out, 
and  the  result  is  a  rising  coefficient,  whether  the  urea  in  the  blood 
be  high  or  low.  The  degree  of  the  impairment  of  renal  func- 
tion, as  indicated  by  the  various  levels  of  Ambard's  coefficient,  is 
indicated  in  Table  XXI. 

"The  test  meal  for  renal  function  which  Mosenthal  and  Lewis 
refer  to  consists  in  the  two  hour  collections  of  urinary  speci- 
mens during  the  day,  while  the  patient  is  on  a  full  diet,  and  of 
a  ten  to  twelve  hour  specimen  at  night.  The  patient  is  given  no 
food  or  fluid  except  at  meal  times.  The  collection  of  the  night 
specimen  is  begun  three  hours  after  the  evening  meal.  Under 
these  circumstances,  a  normal  test  yields  a  maximum  specific 
gravity  of  1018  or  more,  the  specific  gravity  varies  9  points  or 
more  from  the  highest  to  the  lowest,  and  the  night  urine  is  small 
in  amount  (400  c.c.  or  less)  and  of  a  high  specific  gravity  (1018 
or  more).  These  criteria  are  the  same  as  those  originally  de- 
manded of  a  normal  test,  with  the  exception  that  a  difference  of 
9  degrees  between  the  highest  and  the  lowest  observations  has 
been  called  normal,  instead  of  10.  A  lowering  of  the  maximal 
specific  gravity,  a  fixation  of  the  specific  gravity  and  a  nocturnal 
polyuria  are  the  signs  indicating  a  diminished  renal  function. 

"  Table  XXI  gives  the  various  degrees  of  impairment  as  indi- 
cated by  the  test  meal  for  renal  function,  as  compared  with  the 
other  tests.  The  salt,  nitrogen,  and  other  urinary  constituents 
may  be  determined  in  these  specimens,  and  valuable  information 
may  be  obtained  as  to  the  ability  of  the  body  to  excrete  these 
substances.  However,  the  simple  procedure  of  measuring  the 
volume  of  the  urine  and  determining  the  specific  gravity  yields 
sufficient  data  to  give  an  adequate  idea  of  renal  function  in 
many  respects,  and  the  quantitative  chemical  determinations  may 
be  resorted  to  when  more  detailed  information  is  desired.  In 
order  to  study  the  relation  to  one  another  of  the  evidences  of  im- 
paired renal  function  obtained  by  these  various  tests,  a  some- 


300 


BLOOD    AND    URINE  .  CHEMISTRY 


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BLOOD    CHEMISTRY   AND    NEPHRITIS  301 

what  arbitrary  scale  of  four  degrees  of  impairment ;  slight,  moder- 
ate, marked,  and  maximal,  was  determined  on.  The  exact  figures 
which  the  majority  of  experienced  observers  consider  as  indicat- 
ing normal  function,  and  thes*e  various  degrees  of  subnormal 
function,  were  selected  and  the  findings  in  over  200  patients  were 
grouped  in  accordance  with  this  scale." 

The  contention  of  Mosenthal  and  Lewis  is  that  each  one  of 
these  methods  calls  attention  to  a  relative  degree  of  involvement 
of  kidney  function  and  that  each  one  of  them  has  a  significance 
apart  from  the  others.  They  conclude,  therefore,  that  a  compari- 
son according  to  this  method  is  an  extremely  valuable  aid  in  the 
treatment  and  prognosis  of  diseases  of  the  kidney.  They  cor- 
rectly assert  that  so  far  as  nonprotein  nitrogenous  retention  is 
concerned,  differentiation  must  be  made  in  weighing  the  results 
in  the  balance  between  kidney  efficiency,  diet  and  protein  destruc- 
tion. It  must  be  remembered,  however,  that  the  chemical  analysis 
of  blood  offers  perhaps  the  readiest  method  and  the  most  signifi- 
cant in  its  findings  over  all  other  methods  alluded  to  above.  We 
are,  therefore,  inclined  to  believe  that  the  renal  test  meal,  al- 
though of  exceedingly  great  utility,  cannot  approach  in  definite- 
ness  the  blood  chemical  tests.  So  far  as  the  estimation  of  Am- 
bard's  coefficient  is  concerned,  we  are  inclined  to  agree  with 
Chace  and  Myers32  that  this  method  gives  no  additional  informa- 
tion over  the  estimation  of  uric  acid,  urea  and  creatinine  of  the 
blood,  and  the  phenolsulphonephthalein  of  the  urine.  This  is  in 
line  with  the  conclusions  of  Addis  and  Watanabe,33  that  the  rate 
of  urea  excretion  in  man  varies  under  physiological  conditions 
in  a  manner  which  cannot  be  explained  by  the  concentrations  of 
urea  in  the  blood  and  urine. 

The  value  of  the  Ambard  quotient  in  the  estimation  of  renal 
function  has  more  recently  been  taken  up  by  Jonas  and  Austin.34 
They  call  attention  to  the  fact  that  in  addition  to  the  observations 
of  Addis  and  Watanabe,35  Pepper  and  Austin,36  in  dogs,  using, 
however,  total  nitrogen  instead  of  urea,  found  enormous  varia- 
tions in  the  quotient  in  different  animals  and  in  the  same  animal 


32Chace  and  Myers:     Jour.   Am.   Med.   Assn.,    1916,  vol.   Ixvii,   No.    13,   p.   929. 

3:1  Addis  and  Watanabe:     Jour.   Biol.    Chem.,    1916,  vol.   xxiv,   p.   203. 

34Jonas  and  Austin:      Am.   Jour.   Med.    Sc.,  October,    1916,   vol.   clii,   No.   4,  p.   560. 

MAddis  and  Watanabe:     Jour.   Biol.    Chem.,   1916,  vol.   xxiv,  p.   203. 

3GPepper  and  Austin:     Jour.   Biol.   Chem.,    1915,  vol.   xxii,   p.    81. 


302  BLOOD   AND   URINE   CHEMISTRY 

under  different  conditions.  These  two  investigators  studied  the 
Ambard  coefficient  as  modified  by  McLean  on  a  number  of  indi- 
viduals with  presumably  normal  kidneys  and  showed  that  the 
quotient  is  anything  but  constant.  In  this  study  which  was  made 
on  patients  in  the  medical  ward  of  the  University  of  Pennsylvania 
Hospital,  periods  of  72  minutes  were  employed  (or  in  a  few  in- 
stances slightly  larger  periods  up  to  160  minutes),  and  the  blood 
withdrawn  from  the  arm  36  minutes  after  the  period  began.  The 
urea  was  determined  by  the  urease  method  of  Van  Slyke  and 
Cullcn.37  Their  cases  were  divided  into  three  groups;  first, 
cases  in  which  there  was  no  clinical  or  laboratory  evidence  of 
nephritis,  or  of  marked  cardiovascular  disease,  or  of  cardiac 
decompensation ;  second,  cases  with  definite  evidence  of  more  or  less 
severe  nephritis;  third,  a  few  cases  in  which  there  was  no  definite 
nephritis,  but  in  which  there  was  more  or  less  vascular  disease 
or  cardiac  decompensation  or  both.  In  the  first  group,  there  was 
a  wide  variation  of  the  index  in  the  same  individual  on  different 
occasions  and  in  different  individuals.  The  conclusions  of  these 
observers  on  both  normal  and  abnormal  cases  were: 

1.  The  Ambard  formula  in  its  original   form  or  as  modified 
by  McLean  does  not  express  precisely  the  law  of  renal  function 
with  respect  to  the  elimination  of  urea,  and  this  is  particularly 
true  as  regards  the  effect  of  urinary  urea  concentration. 

2.  The  upper  limit  of  blood  urea  in  nonnephritic  and  normal 
individuals  under  ordinary  conditions  of  diet  and  life  is  about 
0.35  gm.  urea  per  liter  of  blood.     Figures  higher  than  this  are, 
under  ordinary  conditions  of  diet,  to  be  considered  evidence  of 
impaired  renal  function. 

3.  Using  McLean's  modification  of  Ambard 's  formula,  it  was 
found  that  in  the  great  majority  of  nephritic  cases  a  lowering  of 
the  index  was  accompanied  by  an  elevation   of  the  blood  urea 
above  normal  limits,  0.35  gm.  per  liter,  and  that  the  index  af- 
forded  no   information   of   diagnostic   or   prognostic   value   that 
could  not  be  as  readily  deduced  from  the  blood  urea  alone. 

4.  In  certain  cases,  the  index  was  found  to  be  lowered  when 
the  blood  urea  was  within  normal  limits.     This  was  especially 
true  in  arteriosclerotic  cases  and  in  cases  with  cardiac  decompen- 


3TVan   Slyke  and   Cullen:     Jour.   Biol.   Cliem.,   1914,  vol.  xix,  p.   211. 


BLOOD    CHEMISTRY    AND    NEPHRITIS  303 

sation,  which  probably  detracts  from  the  clinical  value  of  the  in- 
dex as  compared  with  that  of  the  blood  urea  rather  than  the  re- 
verse, since  it  is  of  importance  to  distinguish  between  cases  of 
vascular  and  renal  character. 

5.  In  the  determination  of  the  index  there  is  a  possibility  of 
error  arising  from  undetected  incomplete  collection  of  the  urine, 
which  cannot  occur  in  the  simple  blood  urea  estimation. 

6.  The  urea  index  estimated  repeatedly  in  the  same  individual 
exhibits  wider  variations  in  the  normal    or    nonnephritic    indi- 
vidual than  in  the  nephritic. 

7.  For  purposes  of  ordinary  clinical  diagnosis  and  prognosis 
the  estimation  of  blood  urea  is  a  more  reliable  and  more  useful 
guide  than  is  the  urea  index  or  the  Ambard  quotient. 

In  a  further  contribution  entitled  "The  Causes  of  Variation 
in  the  Concentration  of  Urea  in  the  Blood  of  Young  Healthy 
Adults,"  Addis  and  Watanabe38  have  shown  that  differences  in 
diet  are  a  cause  of  variation  in  the  concentration  of  urea  in  the 
blood  of  normal  persons  and  that  a  change  from  a  mainly  car- 
bohydrate to  a  protein-fat  diet  is  accompanied  by  an  increase  of 
from  58  to  250  per  cent  in  blood  urea  concentration.  On  a  con- 
stant diet  a  variation  of  from  0.0156  to  0.0438  gm.  urea  per  100 
c.c.  of  blood  was  found  in  tAventy-nine  experiments  on  twenty- 
five  normal  persons.  They  believe  that  differences  in  the  rate  of 
protein  metabolism  are  the  principal  causes  of  the  variation  which 
was  found  in  the  blood  urea  concentration  of  normal  persons 
on  a  constant  diet.  The  subjects  who  had  the  greatest  rate  of 
protein  catabolism  had  the  highest  blood  urea  concentrations, 
while  in  those  subjects  in  whom  the  protein  catabolism  was  least 
the  blood  urea  concentration  was  lowest.  The  blood  urea  con- 
centration of  normal  persons  is  not  maintained  at  a  constant 
level  by  a  proportionate  increase  in  the  rate  of  excretion  of  urea 
from  the  blood  by  the  kidneys,  whenever  there  is  an  increase  in 
the  rate  of  entrance  of  urea  from  the  tissues  into  the  bloo^d.  Al- 
though under  such  circumstances  an  increase  in  the  rate  of  urea 
excretion  occurs,  it  is  not  sufficient  to  prevent  some  rise  in  the 
blood  urea  concentration.  This  rise  takes  place  whether  the 
increased  rate  of  entry  of  urea  from  the  tissues  into  the  blood  is 

3SAddis  and  Watanabe:     Arch.  Int.  Med.,  1917,  vol.  iv,  p.  507. 


304  BLOOD   AND   URINE    CHEMISTRY 

produced  by  a  greater  formation  of  urea  from  protein  taken  as 
food  or  from  the  breaking  down  of  tissue  protein  or  from  the  ab- 
sorption of  preformed  urea  from  the  alimentaiy  tract,  Under 
inconstant  conditions  variation  in  blood  urea  concentration  may 
be  caused  by  alterations  in  the  activity  of  the  kidneys.  The  more 
constant  the  conditions,  the  more  uniform  is  the  action  of  the 
kidney's  in  responding  to  a  rise  in  blood  urea  concentration  by 
a  definite  though  not  directly  proportional  increase  in  the  rate 
of  urea  excretion;  and  there  is  reason  to  believe  that  if  all  the 
conditions  could  be  kept  constant,  no  fluctuations  in  blood  urea 
concentration  would  arise  from  any  inconstancy  in  the  function 
of  the  kidneys  themselves.  But  under  widely  different  conditions 
it  can  be  seen  that  the  kidneys,  even  of  the  same  person,  do  not 
act  in  a  uniform  manner,  so  that  the  same  rise  in  blood  urea 
concentration  may  lead  to  a  greater  rate  of  excretion  under  cer- 
tain conditions  than  it  will  under  others.  They  also  state  it  as 
a  conclusion  that  permanent  individual  peculiarities  play  no  part 
as  a  cause  of  variation  in  the  blood  urea  concentration  of  dif- 
ferent normal  persons.  In  a  group  of  twenty-two  subjects  a 
variation  of  from  0.0225  to  0.06  gm.  urea  per  100  c.c.  of  blood 
was  found  in  a  series  of  106  observations  carried  out  in  the  morn- 
ing before  breakfast.  Practically  the  same  variation  was  shown 
by  one  of  these  subjects,  on  whom  fifty  estimations  were  made. 
The  very  highest  levels  of  blood  urea  concentration  are  ap- 
parently obtainable  only  when  kidney  elimination  is  defective. 
Concentrations  above  0.15  per  cent  speak  decisively  for  renal 
involvement.  But  below  that  figure  judgment  will  be  required 
in  every  case.  A  concentration  of  0.1  per  cent  may  be  very  strong 
evidence  of  renal  deficiency  in  one  case,  while  in  another  in  which 
there  is  reason  to  expect  an  increased  rate  of  protein  catabolism 
or  in  which  unusual  dietary  or  other  conditions  are  present,  it 
may  not  justify  more  than  a  suspicion. 

Furthermore,  regarding  the  efficiency  of  the  Ambard  coeffi- 
cient, we  must  call  attention  to  the  significant  words  of  Folin39 
in  his  Third  Mellon  Lecture  under  the  auspices  of  the  Society 
for  Biologic  Research,  University  of  Pittsburgh,  May  18,  1917, 
on  "Recent  Biochemical  Investigations  on  Blood  and  Urine:" 

:l:'Kolin:      Jour.    Am     Mcd.,   Assn.,    1917,    No.    15,    p.    1209. 


BLOOD    CHEMISTRY    AND   NEPHRITIS  305 

"Before  leaving  the  subject  of  nonprotein  nitrogen  and  urea,  I 
ought  perhaps  to  refer  briefly  once  more  to  the  use  and  value 
of  these  determinations  as  means  of  estimating  the  renal  effi- 
ciency, and  to  the  'refinement'  represented  by  the  so-called  Am- 
bard  coefficient,  which  is  simply  a  combination  of  determinations 
of  urea  in  blood  and  urine.  The  underlying  idea  of  this  com- 
bination is  to  eliminate  any  confusion  which  might  arise  because 
of  changes  in  the  blood  concentration  (of  urea)  due  to  the  level 
of  the  general  protein  metabolism.  In  normal  persons,  as  I  have 
already  indicated,  there  is  no  material  change  in  the  urea  con- 
tent of  the  blood  because  of  changes  in  the  level  of  the  nitrogen 
metabolism.  In  nephritics,  considerable  variations  can  be  pro- 
duced by  changes  in  the  diet;  but  these  changes  are  produced 
very  slowly  so  that  it  usually  requires  several  days  of  low  pro- 
tein feeding  to  produce  a  marked  alteration  in  the  urea  content 
of  the  blood.  Yet  nephritics,  like  normal  persons,  adapt  them- 
selves promptly  to  changes  in  the  protein  content  of  the  food, 
and,  like  normal  persons,  tend  to  remain  in  a  condition  of  nitro- 
gen equilibrium.  The  complicated  mathematical  formulas  intro- 
duced in  connection  with  the  Ambard  coefficient  do  not  tend  to 
increase  one's  confidence  in  that  coefficient.  It  is  difficult  to 
see  how  square  roots  and  cube  roots  can  help  to  elucidate  such 
a  simple  metabolism  proposition.  Work  along  the  lines  of  the 
Ambard  coefficient  is  one  of  the  researches  I  had  in  mind  in  stat- 
ing that  many  metabolism  investigations  based  on  metabolism 
periods  shorter  than  twenty-four  hours  are  now  being  made. 
The  Ambard  period,  seventy-two  minutes,  seems  to  me,  however, 
to  be  too  short.  I  believe  that  a  more  suitable  condition  for  study- 
ing the  effects  of  the  metabolism  level  on  the  urea  retention  will 
be  found  in  connection  with  the  three  hour  metabolism  period 
to  which  I  have  already  referred. ' '  Thus  one  sees  that  so  eprinent 
an  authority  as  Folin  is  rather  skeptical  of  the  benefits  to  be  ob- 
tained from  the  use  of  the  Ambard  coefficient.  The  reference 
which  Folin  alluded  to  regarding  metabolism  investigations  in 
periods  shorter  than  twenty-four  hours  was  the  three  hour  col- 
lection of  samples  of  urine  instead  of  the  older  twenty-four  hour 
collection. 


306  BLOOD    AND    URINE    CHEMISTRY 

It  occurred  to  Gradwohl40  to  look  further  into  the  question  of 
the  comparative  findings  in  spinal  fluid  as  well  as  in  blood,  in 
normal  and  diseased  condition.  His  preliminary  report  follows : 

The  belief  that  considerable  more  data  must  be  obtained  be- 
fore our  knowledge  of  the  chemical  composition  in  spinal  fluid 
is  fully  appraised  was  the  inspiration  for  this  investigation.  This 
is  simply  a  report  of  a  preliminary  series  of  observations  using 
principally  the  spinal  fluids  of  syphilitics  under  Swift-Ellis  treat- 
ment by  means  of  intraspinal  injections  of  salvarsanized  serum 
in  vivo.  Later  on  we  hope  to  .extend  the  observations  to  cover 
some  other  infections  of  the  meninges.  It  must  be  confessed  at 
the  outset  that  we  have  added  but  little  to  the  extensive  informa- 
tion already  at  hand,  yet  in  one  or  two  particulars  this  work 
has  disclosed  a  bare  fact  or  two  that  may  possibly  lead  to  more 
important  observations  and  deductions. 

The  chemistry  of  spinal  fluid  as  compared  to  blood  has  been 
already  extensively  studied.  It  will  be  recalled  that  Hallibur- 
ton41 showed  the  normal  constitution  of  spinal  fluid  in  his  studies 
of  the  fluid  of  a  young  woman  in  whom,  owing  to  some  malforma- 
tion, there  was  a  connection  between  one  nostril  and  the  ven- 
tricles of  the  brain  so  that  the  liquid  dropped  constantly  from 
one  nostril.  Analysis  of  this  fluid  demonstrated  that  it  was  alka- 
line in  reaction  and  of  the  following  composition: 

Per  Cent. 

Water     99.004 

Solids      0.966 

Organic  Solids    0.118 

Inorganic  solids   O.S78 

It  contains  only  a  trace  of  protein,  fibrinogen  and  albumin  be- 
ing absent,  and  it  contains  a  reducing,  nonfermentable  substance 
which  Halliburton  thinks  is  allied  to  pyrocatechin.  It  is  proba- 
bly formed  by  the  secretory  cells  covering  the  choroid  plexus. 

There  has  always  been  some  degree  of  interest  manifested  in 
the  fluctuations  of  the  nonprotein  nitrogenous  constituents  of 
eerebrospinal  fluid  even  before  the  days  of  the  simple  methods 
introduced  into  biologic  chemistry  by  Folin  and  his  followers 
in  this  country.  Most  of  the  data  which  have  been  obtained  with 
respect  to  the  composition  of  this  fluid  in  health  and  disease  were 

4nr,ra<lwohl:     Section  on   Pathology  and  Physiology.  Am.  Mecl.   Assn.,   1917,  pp.   128-141. 
41Hallilwrton:   Jour.    1'hys.,    40,    1910,    vol.    xxx,    Pros.    Phys.    Soc. 


BLOOD   CHEMISTRY   AND   NEPHRITIS  307 

brought  out  by  means  of  the  older  methods.  In  the  past  few  years 
we  have  had  the  opportunity  to  compare  the  data  obtained  by 
the  new  methods  with  those  of  the  older  investigators.  When 
comparative  studies  were  made,  using  the  old  and  the  new  meth- 
ods, the  results  have  been  surprisingly  similar,  which  speaks  well 
for  the  accuracy  of  the  newer  work.  Since  the  substances  which 
we  have  investigated  are  urea  nitrogen,  uric  acid,  creatinine  and 
sugar  in  blood  and  spinal  fluid,  it  might  be  well  to  scan  what 
has  already  been  done  along  these  lines.  The  work  of  E.  K. 
Marshall  and  D.  M.  Davis42  on  the  distribution  and  elimination  of 
urea  from  the  body  demonstrated  that  urea  is  present. in  all  the 
organs  and  tissues  of  the  body.  Again,  the  urea  content  of  all 
organs  and  tissues  is  approximately  uniform,  and  approximately 
equal  to  that  of  the  blood,  both  under  normal  conditions  and  when 
there  is  an  abnormally  large  amount  of  urea  present.  Exceptions 
to  this  rule  are  fat,  which  has  a  low  content,  and  the  urinary 
tract,  which  has  a  high  content.  When  urea  in  solution  is  injected 
intravenously,  it  diffuses  to  all  parts  of  the  body  almost  instantly, 
the  diffusion  being  complete  in  a  few  minutes.  It  is  also  to  be 
noted  that  Marshall  and  Davis  concluded  that  when  the  excre- 
tion of  urea  is  prevented,  the  entire  amount  formed  is  stored  in 
the  body — except  small  amounts  secreted  in  the  bile,  sweat,  etc. — 
and  there  is  no  evidence  of  the  conversion  of  urea  into  other 
substances.  It  is  also  to  be  noted  that  Marshall  and  Davis  be- 
lieved that  there  was  evidence  of  an  increase  in  the  urea  content 
of  tissues  in  cases  where  the  blood  urea  was  abnormally  high. 
They  demonstrated  that  the  amount  of  urea  in  milligrams  in  100 
grams  of  tissues  of  two  normal  dogs  was  as  shown  in  Table  XXII. 
They  give  no  data  on  spinal  fluid  of  dogs  which  were  injected 
with  urea,  nor  do  they  cite  the  figures  on  spinal  fluid  in  the 
nephritics  which  were  studied.  G.  E.  Cullen  and  A.  W.  M.  Ellis43 
further  discuss  the  urea  content  of  human  spinal  fluid  and  blood. 
They  made  twenty-nine  observations  of  blood  and  spinaf  fluid 
which,  by  the  way,  is  the  exact  number  of  analyses  in  the  pres- 
ent study.  The  clinical  diagnosis  in  most  of  their  cases  was  tabes 
and  in  this  respect,  too,  their  work  was  carried  out  on  material 
very  similar  to  our  own.  The  method  used  by  them  was  the  Van 


42Marsha!l,  E.  K.,  and  Davis,  D.  M.:  Jour.  Biol.  Chem.,  1914,  vol.  xviii,  p.  53. 
«Cullen,  G.  E-,  and  Ellis,  A.  W.  M.:  Jour.  Biol.  Chem.,  1915,  vol.  xx.  p.  511. 


308 


BLOOD   AND   URINE    CHEMISTRY 


Slyke  and  Cullen  modification  of  Marshall  urease  method.44  In  63 
per  cent  of  their  determinations  the  difference  between  the  urea 
content  of  the  blood  and  that  of  the  spinal  fluid  was  less  than 

TABLE    XXII 
AMOUNT  OF  UREA  IN  MILLIGRAMS  IN  100  GRAMS  OF  TISSUE 


TISSUE    OR    FLUID 


MILLIGRAMS     UREA     IN     100 
GRAMS  TISSUE  OR  100  C.C.  FLUID 


Dog  13 


Dog  12 


Blood    27 

29 
Blood  serum 29 

Bile 32  21 

Cerebrospinal  fluid    25  21 

Muscle    18 

^ 

OQ  OO 

30 
Brain    jg  20 

I-g    jg_ 

*- - U 

Pancreas    f.  18 

I    2o 

Intestinal  muoosa    J    ^ 

Parotids 29  21 

Thyroid    |  30  37 

Omcntum I  j      ^ 

Lymph  glands   ...  23 

Eye ....  17 

Spinal  cord  i  17 

Testicles    j    ™ 

Prostate  and  urethra ....  52 

Bladder    164 

jig 

Frino    1640 


2  mgms.  per  100  c.c.  The  greatest  difference  was  11  mgms.  per 
100  c.c.  The  urea  values  varied  from  20  to  42  and  from  22  to 
46  mgms.  of  urea  per  100  c.c.  of  serum  and  spinal  fluid  re- 


"Van  Slyke,   D.  D.,  and  Cullen,  G.   K.:     Jour.   Biol.   Chem.,   1914,  vol.  xix,  p.   211. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  309 

spectively.  They  believed  that  these  figures  represented  varia- 
tions within  the  normal  limits.  They  stated  that  the  occasional 
difference  btween  the  spinal  fluid  and  blood  serum  may  be  due 
to  the  rapid  rise  and  fall  of  blood  urea  in  different  stages  of 
protein  digestion.  From  the  nature  of  the  process  of  secretion 
of  spinal  fluid45  one  would  expect  the  changes  in  its  urea  content 
to  lag  behind  those  of  the  blood.  These  results  in  short  were  in 
accordance  with  the  already  well  founded  view  that  the  animal 
tissues  are  in  general  osmotically  permeable  to  urea,  which  there- 
fore tends  to  reach  the  same  level  of  concentration  in  the  dif- 
ferent body  fluids. 

Soper  and  Granat46  have  given  us  a  report  on  ninety-seven  cases 
of  various  diseases,  a  study  of  the  spinal  fluid  with  especial  refer- 
ence to  its  diagnostic  and  prognostic  significance.  Their  series 
comprised  fifty-six  cases  in  which  nephritis  could  be  clinically 
excluded;  twenty-one  cases  of  uremia  resulting  in  death;  eight 
cases  of  nephritis  not  terminating  in  death;  twelve  cases  of  path- 
ologic conditions  with  diagnoses  other  than  uremia  from  which, 
however,  nephritis  could  not  be  excluded.  Their  work  followed 
up  some  of  the  earlier  reports  which  they  extensively  reviewed,  to 
wit,  Froment,47  who  showed  that  all  pathologic  conditions  without 
kidney  involvement  showed  a  negligible  amount  of  urea  in  spinal 
fluid,  namely,  from  none  to  15  mgms.  In  nervous  uremia,  the 
content  attained  as  high  a  figure  as  450  mgms. ;  some  cases  with- 
out a  definite  picture  of  uremia  showed  a  definite  increase  of 
urea,  as  for  instance  250  mgms.  in  cases  of  arteriosclerosis, 
or  Bright 's  disease,  which  at  necropsy  revealed  also  multiple 
cerebral  hemorrhages,  softenings  and  meningitis.  Soper  and 
Granat  made  no  report  on  the  blood  in  their  cases  because  they 
accepted  the  conclusions  in  vogue  prior  to  their  work,  namely, 
that  the  amount  of  urea  does  not  vary  in  the  various  tissues  of 
the  body.  This  is  in  line  with  the  work  of  Javal  and  Adler,48 
Javal  and  Boyet,49  Castaigne  and  Weill,50  Widal,51  and  .further 
work  by  Javal  in  1911,  all  in  agreement  in  that  urea  in  blood  and 

45Cushing,  H.;  Weed,  L.  H.,  and  Wegefarth,  P.:  Jour.  Med.  Research,  1914,  vol. 
xxi,  p.  1. 

4CSoper  and  Granat:     Am.  Jour.  Med.   Sc.,  1914,  vol.  xiii,  p.   131. 

47Froment:     Lyon   med.,    1910,  vol.   cxiv,   p.   269. 

45Javal  and  Adler:     Seances  et  mem.  de  la  Soc.  de  biol.,   1906,  vol.  Ixi,  p.  235. 

4l)Javal  and  Boyet:     Seances  et  mem.  de  la  Soc.   de  biol.,    1910,  vol.    Ixviii,  p.  527 

50Cataigne  and   Weill:     Jour.  med.   franc.,   1911,  vol.  xxxiv. 

51  Widal:     Bull,  et  mem.  Soc.  de  hop.  de  Paris,  1911,  xxxii,  p.  627. 


310  BLOOD   AND   URINE    CHEMISTRY 

in  spinal  fluid  showed  wonderful  parallelism,  both  in  health 
and  disease.  In  the  uremic  cases  studied  by  Soper  and  Granat, 
the  urea  in  spinal  fluid  ranged  as  high  as  200  mgms.  All  their 
cases  with  nephritis  revealed  various  degrees  of  increase  in  urea 
nitrogen  concentration.  Their  conclusions  were,  first,  that  a  spinal 
fluid  urea  content  higher  than  200  mgms.  per  100  c.c.  indicates  a 
severe  uremia  and  a  rapidly  fatal  termination.  Secondly,  a  con- 
tent between  100  and  200  mgms.  means  a  rapidly  fatal  termination 
in  the  majority  of  cases  of  nephritis.  Thirdly,  a  content  between 
50  and  100  mgms.  does  not  permit  of  any  definite  conclusions 
either  as  regards  diagnosis  or  prognosis.  Such  a  content  is,  how- 
ever, suggestive  of  severe  urea  retention  and  must  be  taken 
into  consideration  in  the  diagnosis  of  the  condition.  They  as- 
serted their  belief  that  the  determination  of  the  presence  or 
absence  of  urea  retention  in  the  body  fluids  will  go  far  to  clear 
up  certain  difficult  problems  where  the  question  of  uremia  enters 
into  consideration. 

The  question  of  the  sugar  content  or  the  reducing  substances 
in  spinal  fluid  has  been  a  most  absorbing  one  to  many  investi- 
gators. All  authorities  are  agreed  that  sugar  is  present  in  spinal 
fluid  although  there  may  be  present  mucinoid  matter,  pyrocat- 
echin.  Von  Jaksch52  in  twenty  normal  cases  found  sugar  in 
from  0.06  to  0.08  per  cent;  Nawratzki,53  using  Allihn's  method, 
found  0.046  per  cent;  Kopetzky,54  witn  Benedict's  method,  in 
eight  cases  found  an  average  of  0.046  per  cent.  Mestrezat  found 
an  average  of  0.48  to  0.53  per  cent.  Hopkins,55  in  his  work  on 
this  question  on  the  sugar  content  in  spinal  fluid  in  meningitis 
and  other  diseases,  found  values  between  0.06  and  0.075  per  cent 
in  normal  cases.  Hopkins  has  shown  that  the  blood  sugar  is  in- 
creased in  meningitis  and  the  sugar  in  spinal  fluid  decreased. 
He  states  that  it  may  be  that  the  hyperglycemia  of  meningitis 
is  at  first  accompanied  by  an  increase  of  sugar  in  spinal  fluid 
which  is  later  destroyed  by  the  organisms  present.  Hopkins  used 
a  modification  of  Bang's  method  in  his  series  o£  'cases  just  alluded 
to.  He  later  controlled  Bang's  method  with  Benedict's  colori- 

-Von  Jak^-li:      Klin.   Diagnostik  m.  inncrc  Krankli.,  5th   Kd.,  p.   Sf.7. 
•"•"Nawrati'.ki:      Xtschr.    f.    pliys.    Chcmic,    1897,   vol.    xiii. 

MKopetzkv:  Ztschr.  f.  Olircnhcilk.  u.  f.  d.  Krank.  d.  I.uftwcg.,  1913,  vol.  Ixviii,  pp. 
1-19. 

"Hopkins:     Am.   Jour.   Mod.    Sc.,    1915. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  311 

metric  method  and  found  results  about  the  same.  The  prognostic 
and  diagnostic  value  of  the  search  for  reducing  substances  in 
spinal  fluid  has  been  previously  noted  by  Sicard  and  Rousseau,56 
Silvestrini  and  Nestri,57  Mestrezat,58  Kopetzky,54  Connal,59  Jacob60 
and  others.  Kopetzky  believes  that  the  spinal  fluid  ought  to  be 
quickly  examined  for  sugar  in  suspected  cases  of  meningitis  be- 
cause of  the  rapid  reduction  of  sugar  by  the  bacteria  present, 
therefore  the  reduction  of  sugar  would  be  a  very  early  sign  of  menin- 
gitis. Hopkins,  in  his  series  of  cases  of  meningitis,  calls  atten- 
tion to  the  prognostic  value  of  such  an  examination,  namely,  as 
the  bacteria  lose  their  virulence  and  their  ability  to  break  up 
sugar  and  as  they  become  more  difficult  to  cultivate  from  the 
fluid,  the  sugar  content  gradually  increases  and  is  in  turn  fol- 
lowed by  convalescence.  However,  investigators  have  apparently 
overlooked  the  fact  as  noted  by  Hopkins,  that  the  injection  of 
Flexner's  serum  itself  may  be  the  cause  for  the  increase  in  spinal 
fluid  sugar,  inasmuch  as  this  serum  contains  as  much  as  0.11 
per  cent,  a  figure  considerably  higher  than  that  of  a  normal  spinal 
fluid.  In  twenty-two  cases  of  meningitis,  Hopkins  showed  sugar 
in  spinal  fluid  to  vary  from  0.015  to  0.079  per  cent.  He  noted  that 
the  Fehling  reaction,  although  slight  in  these  cases,  was  not  al- 
together absent,  although  frequently  considerably  masked  by  the 
strong  biuret  reaction  present,  due  to  the  increased  protein  con- 
tent. He  showed  also  in  eight  cases  of  diabetes  that  there  was 
a  striking  increase  in  the  sugar  content  of  the  fluid  which,  how- 
ever, remained  lower  than  that  of  the  blood.  In  one  case  with 
a  blood  sugar  of  0.623  per  cent  there  was  a  corresponding  spinal 
fluid  sugar  of  0.66  per  cent.  In  a  series  of  eleven  cases  of  va- 
rious infections,  the  sugar  in  spinal  fluid  corresponded  to  the 
normal  quantities.  In  ten  cases  of  various  intoxications,  mor- 
phinism, alcoholism,  etc.,  showed  inconstant  values.  One  case  of 
delirium  tremens  showed  a  pronounced  increase.  In  a  case  of 
atropin  poisoning  the  low  value  of  0.57  per  cent  was  observed ; 
the  author  believed  that  this  may  be  in  line  with  the  view  of  the 
secretory  theory  of  spinal  fluid  and  of  the  possible  action  of 


'Sicard   and   Rousseau:     Jour.    Phys.    Chem. 

'TSilvestrini  and  Nestri:     quoted  by  Trerotc 

in.   d.   Facolta  di  med.,   1913,  vol.   xi,   p.    101-324. 

^Mestrezat:     Jour,    de  Phys.   et  de   Path,   genl.,    1912,   vol.   xiv,   pp.   504-508, 
30Connal:     Quart.  Tour.  Med.,  1909-10,  No.  3,  p.   152. 
"•Jacob:     Brit.  Med.  Jour.,  1912,  p.   1096. 


r"Sicard   and   Rousseau:     Jour.    Phys.    Chem.,   October,    1914. 

"Silvestrini  and  Nestri:     quoted  by  Trerotoli   in   article  on   Spinal   Fluid  in   Nephritis: 
Ann.   d.   Facolta  di  med.,   1913,  vol.   xi,  p.    101-324. 


312  BLOOD   AND   URINE    CHEMISTRY 

atropin  on  the  choroid  plexus,  though  Dixon  and  Halliburton 
state  that  atropin  does  not  check  the  secretion  of  spinal  fluid  in 
dogs  when  administered  in  the  usual  size  doses.  In  fourteen 
cases  of  nephritis  the  spinal  fluid  sugar  was  rather  high,  which 
may  be  in  line  with  the  fact  that  some  nephritics  with  hyperten- 
sion show  a  concomitant  hyperglycemia.  In  twenty-nine  cases 
of  syphilis  the  values  were  usually  low.  Kaplan,61  in  a  study  of 
paresis  and  cerebrospinal  syphilis,  found  in  untreated  cases  of 
general  paresis  that  Fehling  's  reaction  was  always  positive,  while 
in  cerebrospinal  syphilis  it  was  sometimes  absent.  Biach,  Kerl 
and  Kabler,62  working  on  the  question  of  the  changes  in  the 
spinal  fluid  after  the  administration  of  neosalvarsan,  using  Bang's 
method,  found  that  with  the  use  of  neosalvarsan  the  spinal  fluid 
content  increased,  one  case  reaching  0.34  where  it  has  been  as  low 
as  0.09. 

Our  own  cases,  twenty-nine  in  all,  are  given  in  Table  XXIII. 

It  will  be  noted,  that  there  are  twelve  examinations  in  cases 
of  tabes  dorsalis,  all  under  the  Swift-Ellis  treatment  by  means 
of  intraspinal  injections  of  salvarsanized  serum.  There  is  one 
case  of  multiple  sclerosis;  one  case  of  severe  stricture  of  the 
urethra;  one  case  of  tubercular  meningitis;  one  case  of  diabetes 
mellitus  with  tuberculosis  pulmonalis;  one  mild  case  of  diabetes 
mellitus ;  four  cases  of  primary  cardiac  disease  with  hypertension ; 
two  cases  of  uremic  nephritis  and  one  case  of  moderately  ad- 
vanced nephritis,  and  two  cases  of  arteriosclerosis.  We  under- 
took to  make  an  examination  of  the  blood  and  spinal  fluid  in 
all  these  cases,  testing  for  urea  nitrogen,  uric  acid,  creatinine  and 
sugar.  The  Marshall  urease  method  was  used  for  the  estimation 
of  urea  nitrogen ;  the  Folin  and  Denis  method  for  the  estimation 
of  uric  acid;  the  Folin  test  for  creatinin  and  the  Benedict  and 
Lewis  methods  for  sugar.  The  blood  was  oxalated  and  with- 
drawn at  the  same  time  that  the  lumbar  puncture  was  made  for 
the  withdrawal  of  spinal  fluid.  The  estimations  were  made  im- 
mediately in  all  cases. 

In  critically  surveying  our  figures  it  will  be  noted  first  that 
we  have  confirmed  the  work  of  those  who  have  maintained  that 
the  percentage  of  urea  is  the  same  in  blood,  spinal  fluid  and  other 


«=Kabler 


:      Am.   Jour.    Insanity,    1912-13,   vol.   Ixix,   p.    336. 
:      Wein.   klin.    Wclmschr.,    1914,   No.    30,   p.    1098. 


BLOOD    CHEMISTRY    AND    NEPHRITIS 


313 


tissues  of  the  body.  Case  1,  thermic  fever,  with  retention  of  all 
ingredients,  showed  45  mgms.  in  blood  and  44  mgms.  in  spinal 
fluid.  Case  22,  K.  V.,  uremic  nephritis,  showed  112  mgms.  in 
blood  and  104  in  spinal  fluid.  There  was  also  a  difference  of  four 


TABLE  XXIII 

EXAMINATION  OF  THE  BLOOD  AND  SPINAL  FLUID 


Milligrams  per  100  c.c. 

Per  Cent 

No. 

Name 

UreaN 

Uric  Acid 

Creatinine 

Sugar 

Remarks 

Blood 

Spinal 
Fluid 

Blood 

Spinal 
Fluid 

,  1  Spinal 
Blood  |  rfuid 

,  1  Spinal 
Blood  |  rf^ 

1 

A.  F. 

45 

44 

7.1 

0.88 

3.94 

2.40 

0.156 

0.100 

Thermic  fever. 

2 

E.  K. 

12 

11 

4.5 

0.77 

2.11 

1.48 

0.105 

0.056 

Tabes.   Swift-Ellis 

Treatment. 

3 

J.  S. 

12 

12.5 

3.8 

0.49 

1.48 

0.45 

0.108 

0.058 

Tabes.   Swift-Ellis 

treatment. 

4 

H.  T. 

11 

11 

3.6 

0 

0.90 

0.54 

0.105 

0.054 

Tabes.   Swift-Ellis 

treatment. 

5 

H.  T. 

13 

13 

3.3 

0 

1.07 

0.45 

0.090 

0.050 

See  Case  No.  4. 

6 

D.  J. 

12 

12 

3.2 

0.79 

0.90 

0.54 

0.090 

0.056 

Advanced  tabes. 

"S-E-T."* 

7 

A.  H. 

12 

HI 

2.4 

0 

1.34 

0.63 

0.117 

0.070 

Old  case  of  Tabes. 

"S-E-T." 

8 

L.  M. 

11 

9 

2.2 

t 

1.16 

0.98 

0.120 

0.066 

Locomotor  ataxia. 

"S-E-T." 

9 

D.  W. 

12 

12 

2.5 

t 

1.16 

0.45 

0.106 

0.050 

Tabes  (beginning). 

"S-E-T." 

10 

P.  D. 

11 

11 

2.9 

0.30 

1.34 

1.03 

0.114 

0.086 

Tabes  (advanced). 

"S-E-T." 

11 

A.  J. 

14 

13.5 

3.8 

0.20 

.34 

0.89 

0.108 

0  076 

Multiple  sclerosis. 

12 

F.  B. 

12 

12 

2.0 

t 

.20 

0.63 

0.111 

0.056 

Tabes.   Swift-Ellis 

treatment. 

13 

F.  B. 

13 

13 

3.1 

0.34 

.25 

0.89 

0.117 

0.052 

See  Case  No.  12. 

14 

P.  K. 

12 

11 

2.5 

0.16 

.20 

0.45 

0.118 

0.054 

Stricture 

15 
16 

G.  S. 

w.s. 

99 
25 

99 

24.5 

9.8 
5.7 

1.64 
1.39 

.26 
.62 

Q.N.St 
0.80 

0.144 
0.114 

Q.N.SJ 
0.086 

Uremia. 
Uremia. 

17 

J.  S. 

12.5 

12.5 

3.1 

1.30 

.00 

0.61 

0.120 

0 

Tubercular  meningitis 

18 

C.  P. 

12 

12 

Q.N.S 

Q.N.S 

.34 

0.45 

0.264 

0.130 

Diabetes  and  tuber- 
culosis. 

19 

F.  B. 

22 

22 

Q.N.S 

Q.N.S 

.34 

0.45 

0.180 

0.120 

Diabetes. 

20 

A.  K. 

16 

16 

4.8 

1.14 

.79 

1.52 

0.126 

0.072 

Cardiac 

21 

E.  K. 

11 

11 

3  0 

0  32 

51 

0  80 

0  111 

0  060 

Cardiac. 

22 

K.  V. 

112 

104 

5.9 

1.30 

1    .20 

4.56 

0.164 

0.102 

Uremic  nephritis. 

23 

M.  K. 

15 

16 

3.4 

0.37 

.61 

0.45 

0.084 

0.070 

Cardiac 

24 

P.  R. 

12 

12 

2.0 

0.61 

.61 

0.63 

0.098 

0.064 

Cardiac. 

25 

H.  F. 

99 

95 

7.7 

2.20 

.12 

3.03 

0.156 

0.074 

Uremic  nephritis 

26 

D.  J. 

16 

14 

3.2 

0.53 

.97 

1.07 

0.117 

0.060 

Nephritis. 

27 

D.  N. 

14 

13 

4.1 

0 

.16 

0.81 

0.105 

0.076 

Tabes.   Swift-Ellis 

treatment. 

28 

F.  G. 

108 

99 

9.8 

1.90 

4.48 

2.60 

0.148 

0.082 

Arterial  sclerosis. 

29 

C.  P. 

14 

14 

2.4 

0.21 

1.25 

0.81 

0.111 

0.058 

Nephritis. 
Arterial  sclerosis. 

*  "S-E-T"  =  Swift-Ellis  treatment.                         J  Q.  N.  S.=  Quantity  not  sufficient.    * 

t=  Trace.     Color  too  faint  to  read. 

points  in  Case  25,  99  in  blood  and  95  in  spinal  fluid.  Case  28, 
arteriosclerosis  with  nephritis,  showed  108  mgms.  in  blood  and 
99  in  spinal  fluid.  This  discrepancy  was  not  seen  in  the  other 
cases.  It  is  so  slight,  too,  that  it  may  be  considered  negligible. 


314 


BLOOD   AND    URINE    CHEMISTRY 


TABLE  XXIV 

SYPHILIS 

Blood 

Case  No. 

Spinal    Fluid 

2 
3 
4 
5 
6 
7 
8 
9 
10 
12 
13 
27 
Average 

Sugar                         Creatinine 
1.88                             1.42 
1.86                            3.29 
1.94                            1.66 
1.80                            2.38 
1.60                            1.66 
1.67                            2.12 
1.81                              1.18 
2.12                             2.58 
1.21                                .30 
2.00                                .90 
2.25                                .40 
1.38                                .42 
1.79                                .86 

Uric   Acid 
5.80 
7.75 
None  in  spinal  fluid 
None  in  spinal  fluid 
4.05 
None  in  spinal  fluid 
Trace 
Trace 
9.66 
Trace 
9.11 
None  in  spinal  fluid 
7.27 

TABLE  XXV 

DIABETES 

Case  No. 

Blood 
Quotient:     - 
Spinal  Fluid 

18 
19 
Average 

Sugar                        Creatinine 
2.03                           3.00 
1.50                            3.00 
1.76                            3.00 

Uric  Acid 
Not  made 
Not  made 

TABLE  XXVI 

TUBERCULOSIS 

Blood 

Case  No. 

Spinal  Fluid 

18 

Sugar                        Creatinine 
2.03                             3.00 

Uric  Acid 
Not  made 

TABLE  XXVII 

NEPHRITIS 

Blood 

Case  No. 

Spinal  Fluid 

15 
18 

22 
25 
26 
28 
Average 

Sugar                       Creatinin.* 
Not  made                     Not  made 
1.21                             2.02 
1.60                             2.23 
2.11                             2.02 
1  .  95                             1  .  83 
1  .  80                             1  .  72 
1.73                            1.98 

Uric  Acid 
5.97 
4.10 
4.53 
3.50 
6.04 
5.16 
5.86 

BLOOD    CHEMISTRY   AND   NEPHRITIS 


315 


TABLE  XXVIII 

CARDIAC  LESIONS 

Blood 

Case  No. 

Spinal  Fluid 

20 
21 
23 
24 
Average 

Sugar                        Creatinina 
.75                            1.18 
.82                            1.88 
.20                            3.58 
.53                            2.55 
.57                             2.30 

Uric  Acid 
4.21 
9.27 
9.19 
3.28 
6.49 

TABLE  XXIX 

STRICTURE 

Blood 

Case  No. 

Spinal  Fluid 

14 

Sugar                         Creatinine 
2.18                             2.67 

Uric  Acid 
15.62 

TABLE  XXX 

MENINGITIS 

Blood 

Case  No. 

Spinal  Fluid 

17 

Sugar                        Creatinine 
No  sugar  present             1.61 

Uric  Acid 

2  .  38 

TABLE  XXXI 

ARTERIOSCLEROSIS 

Blood 

Case  No. 

Spinal  Fluid 

11 
28 
29 
Average 

Sugar                        Creatinins 
1.42                             1.51 
1.80                             1.72 
1.93                             1.54 
1.72                             1.59 

Uric  Acid 
19.00 
5.16 
11.43 
11.86 

TABLE  XXXII 

THERMIC  FEVER 

*• 

Blood 

Case  No. 

Spinal  Fluid 

1 

Sugar                         Creatinine 
1.56                             1.64 

Uric  Acid 
8.06 

316  BLOOD   AND    URINE    CHEMISTRY 

Possibly  the  most  interesting  fact  which  seems  to  have  been 
demonstrated  in  our  work  is  seen  in  the  uric  acid  figures.  \\7e 
have  expressed  the  quotient  of  uric  acid  below,  that  is,  the  factor 
of  dividing  the  amount  of  uric  acid  in  blood  by  the  amount  in 
spinal  fluid. 

It  will  be  seen  that  it  is  as  much  as  nine  or  ten  in  the  tabetic 
cases.  In  other  words,  there  is  a  sharp  decline  in  the  amount 
of  uric  acid  in  spinal  fluid  in  these  cases  of  syphilis  of  the  cere- 
brospinal  or  spinal  axis.  There  is  a  diminished  amount  in  other 
conditions  but  not  nearly  so  great  as  is  the  case  in  syphilis 
cerebrospinalis.  It  seems  therefore  that  the  diffusibility  of  uric 
acid  is  not  nearly  so  great  as  is  that  of  urea  nitrogen.  In  Cases 
4,  5,  7,  8,  9,  12  and  27  there  was  no  uric  acid  in  the  spinal  fluid, 
even  though  the  amount  in  the  blood  in  these  cases  was  within 
the  normal  limits.  Attention  is  called  to  the  figures  in  the  cases 
of  nephritis;  while  there  was  a  diminished  amount  of  uric  acid 
in  spinal  fluid  as  compared  to  that  in  the  blood,  still  it  did  not 
reach  the  low  figure  in  spinal  syphilis. 

Regarding  the  creatinine  figures,  there  was  a  uniform  decrease 
in  the  quantity  in  spinal  fluid  as  compared  to  blood,  but  in  no 
way  did  it  parallel  the  figures  for  uric  acid.  As  a  rule  there  was 
usually  about  half  as  much  creatinine  in  spinal  fluid  as  there  was 
in  blood,  regardless  of  the  clinical  condition. 

The  sugar  content  of  spinal  fluid  in  this  series  shows  a  de- 
crease under  all  conditions,  in  most  cases  about  one-half  as  much 
in  the  fluid  as  in  the  blood.  We  had  but  one  case  of  definite 
tuberculous  meningitis  in  this  series  but  the  figures  here  seem 
to  be  in  accord  with  those  already  quoted,  namely,  that  in  this 
condition  sugar  disappears  from  the  spinal  fluid.  In  Case  17 
there  was  no  sugar  in  the  spinal  fluid,  whereas  the  blood  showed 
the  normal  amount,  0.12  per  cent. 

Conclusions 

1.  Urea  nitrogen  is  present  in  equal  amount  in  blood  and  spinal 
fluid  in  cases  of  syphilis  of  the  nervous  system,  nephritis,  tuber- 
culous meningitis  and  very  probably  under  all  conditions. 

2.  There  is  a  marked  decrease  in  the  amount  of  uric  acid  in  the 
spinal  fluid  of  cases  of  syphilis  of  the  nervous  system,  the  ratio 
being  about  one  of  the  former  to  ten  of  the  latter. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  317 

3.  There  is  always  less  uric  acid  in  spinal  fluid  than  in  blood. 

4.  The  quantity  of  creatinine  is  less  in  spinal  fluid  than  in  blood. 

5.  The  quantity  of  sugar  is  less  in  spinal  fluid  than  in  blood 
under  the  conditions  of  disease  covered  by  this  investigation. 
In  tuberculous  meningitis,  according  to  past  records  and  our  own 
observations,  sugar  may  be  greatly  reduced  or  even  absent  in 
spinal  fluid. 

Blood  Sugar  and  Nephritis. 

Attention  must  be  called  to  the  fact  that  diabetes  may  often 
be  complicated  by  nephritis  and  that,  therefore,  the  study  of  blood 
chemistry  of  these  individuals  is  most  imperative.  The  presence 
of  undue  sugar  in  the  blood  and  urine  of  these  cases  calls  at- 
tention to  the  estimation  of  all  the  other  blood  ingredients  com- 
monly searched  for  in  nephritis.  It  must  also  be  remembered 
that  hyperglycemia  exists  in  severe  nephritis ;  this  has  been  recog- 
nized for  some  time  by  Bang,63  Neubauer,64  Holly  and  Opper- 
mann,65  and  Hopkins.00  Myers  and  Bailey67  allude  to  it  in  con- 
nection with  an  observation  of  a  number  of  hospital  cases.  So  we 
may  have  hyperglycemia  with  nephritis  and  nephritis  complicat- 
ing diabetes.  Severe  nephritis  seems  to  reduce  the  permeability 
of  the  kidney  for  sugar.  In  one  of  their  fatal  cases,  Myers  and 
Bailey  point  to  the  marked  nephritic  symptoms,  coupled  with  a 
high  creatinine  value  of  4.7,  indicating  that  the  nephritis  had  as 
much  to  do  with  the  cause  of  death  as  the  diabetes.  In  the  three 
fatal  cases  of  diabetes  which  they  studied,  the  first  two  showed  a 
normal  creatinine  value,  with  an  obscure  cause  of  death  in  both, 
scarcely  acidosis  in  their  opinion.  Myers  and  Bailey  reported  in 
this  paper  a  number  of  cases  of  nephritis  with  as  high  a  blood 
sugar  content  as  0.20  per  cent.  In  four  cases  of  interstitial  neph- 
ritis glycosuria  was  absent,  while  mild  glycosuria  was  present  in 
the  two  cases  of  parenchymatous  nephritis  with  edema.  Many  of 
their  cases  gave  evidence  of  nephritis  complicating  .diabetes. 
Mosenthal68  has  recently  emphasized  the  fact  that  cases  of  inter- 
stitial nephritis  secrete  a  urine  of  a  very  constant  low  specific 


"Bang:     Der  Blutzucker.  Wiesbaden,   1913,   p.   128. 

64Xeubauer:      Biochem.    Ztschr.,    1910,   vol.    xxv,    p.    284. 

^Rolly  and   Oppermann:      Biochem.   Ztschr.,    1913,  vol.   xlviii,   p.   268. 

""Hopkins:     Am.   Jour.    Med.    Sc.,    1915,   vol.    cxlix,   p.    254. 

67Myers  and  Bailey:     Jour.   Biol.   Chem.,   1916,  vol.  xxiv,   No.   2,  p.   147. 

^Mosenthal:     Arch.  Int.  Med.,  1915,  vol.  xvi,  p.  733. 


318  BLOOD   AND   URINE    CHEMISTRY 

gravity  with  low  content  of  chloride  and  nitrogen.  It  is  possible 
that  this  same  factor  may  have  some  influence  on  the  concentra- 
tion of  urinary  sugar.  Myers  and  Bailey  report  one  case  of  1.10 
per  cent  of  blood  sugar,  possibly  the  highest  figure  on  record, 
and  only  0.5  per  cent  in  the  urine.  They  state  that  if  the  neph- 
ritis is  of  the  interstitial  type,  the  data  obtained  for  uncompli- 
cated nephritis  explain  the  elevation  of  the  threshold  point  of 
sugar  excretion  in  these  advanced  cases  of  diabetes.  The  neph- 
ritis may  further  explain  the  difficulty  in  reducing  the  blood  sugar 
of  these  cases  to  normal  by  restrictions  in  the  carbohydrate  in- 
take. The  use  of  lactose  as  a  functional  kidney  test  has  shown 
quickly  the  permeability  of  the  kidney  for  this  sugar  in  nephritis. 
As  an  index  of  the  ability  of  the  kidney  to  excrete  sugar,  it  seems 
possible  that  the  ratio  between  the  sugar  of  the  blood  and  urine 
might  be  worked  out  somewhat  after  the  method  of  McLean,09 
as  recently  employed  for  urea  and  chlorides. 

Blood  Chemistry  and  Surgery. 

Operative  risk  is  largely  judged  by  kidney  function.  Operative 
risk  means  ability  to  stand  the  anesthetic  and  to  carry  on  the 
functions  in  the  presence  of  an  overwhelming  change  in  the  organ- 
ism caused  by  the  operative  attack.  The  methods  usually  in  vogue 
in  surgical  institutions  to  judge  kidney  function  are  the  routine 
urinary  analysis  and  the  use  of  the  phenolsulphonephthaleiii  test 
for  kidney  efficiency.  From  what  has  gone  before,  it  seems  ra- 
tional to  include  in  this  survey  of  the  patient  a  very  complete 
blood  chemical  analysis.  Since  the  data  already  obtained  by 
blood  chemical  methods  have  so  often  upset  and  changed  medical 
diagnoses  and  prognoses,  it  goes  without  saying  that  the  same  set 
of  conditions  will  occur  when  these  tests  are  used  in  connection 
with  surgical  procedures.  Certainly  the  surgeon  who  proceeds 
to  operate  after  having  been  assured  that  the  blood  sugar,  urea 
nitrogen,  uric  acid,  and  creatinine  of  his  patient  are  within  nor- 
mal bounds,  will  have  far  less  cause  for  fear  of  unforeseen  catas- 
trophe to  his  patients  than  those  who  rely  simply  on  the  tests  com- 
monly used  with  respect  to  the  urine.  Possibly  in  no  department 
of  surgery  are  these  tests  so  much  indicated  as  in  urology  in  con- 


""McLean:     Jour.    Kxper.   Mod.,   1915,  vol.   xxii,   pp.   212,   366. 


BLOOD    CHEMISTRY    AND   NEPHRITIS  319 

ncction  with  operative  procedures  upon  the  old  men-candidates 
for  prostatectomy.  Kemarkable  lowering  of  the  death  rate  from 
this  operation  has  occurred  since^  the  institution  of  rational  prepa- 
ration of  these  bad  risks  for  surgery  have  been  carried  out,  with 
free  washing  of  the  kidney  for  days  prior  to  the  operation  by 
copious  drinking  of  water,  the  use  of  diuretics,  the  awaiting  un- 
til cardiac  and  renal  functions  are  within  rational  limits  of  health. 
These  patients  are  examined  by  the  routine  methods  of  urine 
analysis,  special  attention  being  paid  to  the  output  of  urea  with- 
out much  attention  to  the  blood  findings.  Estimation  of  urea 
without  blood  urea  determinations  are  necessarily  of  but  little 
scientific  benefit.  These  tests  should  be  supplemented  by  urea 
blood  estimations  as  well  as  blood  sugar  and  uric  acid  and  crea tin- 
in  e  tests. 

Aside  from  the  preliminary  survey  of  these  operative  patients, 
the  surgeon  may  well  utilize  the  methods  of  blood  chemistry  for 
determination  of  the  impending  onset  of  acidosis  in  his  patients 
after  operation.  We  hear  much  of  the  term  acidosis  in  the  surgical 
hospital,  but  hear  but  little  of  its  exact  diagnosis.  Certain  it  is, 
much  that  is  called  acidosis  in  the  way  of  a  surgical  operation  is 
not  acidosis  at  all  and  perhaps  cases  of  acidosis  occur  that  are 
never  recognized.  It  is  here  that  blood  chemistry  must  come  for- 
ward to  settle  this  question.  A  rapid  estimation  of  the  combining 
power  of  the  patient's  blood  plasma  by  the  Van  Slyke  or  Marriott 
method  will  speedily  clear  the  picture  so  far  as  acidosis  is  con- 
cerned. 

In  connection  with  the  use  of  blood  chemical  methods  in  sur- 
gery Gradwohl  and  Scherck70  reported  before  the  American 
Urological  Association  at  the  1917  meeting  results  with  these 
methods  in  estimating  kidney  function  in  surgical  cases,  con- 
fining their  work  mainly  to  obstructive  conditions  of  the  lower 
urinary  tract  in  which  there  was  more  or  less  back  pressure  on 
the  kidneys.  Some  of  these  cases  suffered  from  nephritis  as  well. 
In  this  paper  we  stated  our  views  on  this  question  about  as  fol- 
lows: "It  has  always  seemed  plausible  to  expect  more  important 
information  from  chemical  studies  of  this  kind  than  from  the 


:°Gradwohl  and  Scherck:  A  Study  of  Chemical  Blood  Findings  in  Various  Surgical 
Conditions,  with  Special  Reference  to  Prognosis,  and  a  Comparison  with  the  Phenol- 
sulphonephthalein  Output,  Interstate  Med.,  Jour.,  1917,  vol.  xxiv,  No.  9. 


•  )20  BLOOD    AND    URINE    CHEMISTRY 

power  of  the  kidneys  to  eliminate  an  inert  dyestuff  such  as 
phenolsulphonephthalein.  We  assume  that  the  cause  of  the  se- 
vere symptoms  in  nephritis  is  impending  or  advancing  uremia, 
and  that  the  cause  of  the  uremia  is  deficient  elimination  through 
the  kidneys.  Whether  the  ingredients  in  blood  which  we  are 
analyzing  represent  the  substances  themselves  that  produce  the 
toxic  symptoms,  or  whether  they  are  simply  an  index  of  the 
toxic  state,  is  beside  the  point  for  the  purpose  in  hand.  We  be- 
lieved from  our  studies  on  internal  medical  problems  that  the  blood 
chemical  methods  on  this,  a  most  important  surgical  problem, 
would  serve  us  in  good  stead. 

"The  estimation  of  kidney  function  by  the  determination  of 
the  ease  and  speed  with  which  a  chemical  dye  can  be  eliminated 
through  them  seems  somewhat  rash  in  theory  and  in  practice. 
Because  a  dyestuff  is  eliminated  with  a  certain  degree  of  ease, 
it  does  not  follow  that  the  by-products  of  metabolism  are  similarly 
passed  out  through  such  kidneys.  In  referring  to  chemical  dye 
tests,  we  allude  more  particularly  to  the  test  of  Geraghty  and 
Rowntree,  for  of  all  the  color  producing  substances  that  are  used  in 
kidney  functional  work  phenolsulphonephthalein  is  the  most  com- 
monly used  and  quoted  because  of  its  ease  of  administration,  its 
harmlessness,  and  the  rapidity  of  testing  for  its  presence  in  voided 
or  catheterized  urine.  Within  certain  limitations  it  gives  a  fairly 
good  picture  of  kidney  function,  still  it  manifestly  cannot  give 
the  observer  the  same  intimate  picture  of  metabolic  processes 
and  real  kidney  efficiency  or  deficiency  which  goes  with  a  com- 
plete blood  chemical  analysis. 

"The  work  of  Folin,  Fitz,  Frothingham  and  Denis71  on  'The 
Relation  between  Non-Protein  Nitrogen  Retention  and  Phenol- 
sulphonephthalein Excretion  in  Experimental  Uranium  Nephri- 
tis,' gives  a  very  good  view  of  the  exact  value  of  each  method 
of  investigation  from  a  purely  experimental  standpoint.  These 
experiments  showed  that  there  was  a  wide  difference  in  the 
figures  of  the  phenolsulphonephthalein  test  and  the  blood  chem- 
ical data;  that  at  the  beginning  of  the  nephritis,  the  phenolsul- 
phonephthalein elimination  dropped  more  rapidly  than  the  ac- 
cumulation of  nonprotein  nitrogen  and  urea  of  the  blood.  During 

"Frothingham,    Fitz,    Folin,    Denis:      Arch.    Int.    Med.,    1913,   vol.    xii,   p.    245. 


BLOOD    CHEMISTRY    AND   NEPHRITIS  321 

the  course  of  the  disease  the  height  of  the  nitrogenous  accumula- 
tion is  reached  from  two  to  three  days  later  than  the  lowest  level 
of  the  phenolsurphonephthalein  excretion.  Nonprotein  nitrogen 
and  urea  accumulated  in  the  blood,  and  returned  to  normal  gradu- 
ally in  these  rabbits  as  recovery  of  the  kidney  occurred.  These 
observers  maintained  that  in  general,  these  two  tests  paralleled 
each  other,  but  with  this  essential  difference:  the  amount  of 
phenolsulphonephthalein  excretion  showed  the  kidney  function  at 
the  moment;  the  amount  of  nonprotein  nitrogen  and  urea  in  the 
blood  is  rather  a  measure  of  an  accumulating  difference  between 
the  amounts  of  waste  nitrogen  produced  in  the  metabolism  and 
the  amounts  eliminated  by  the  kidneys.  The  time  element,  the 
duration  of  the  condition,  constitutes  therefore  a  most  important 
factor  in  the  comparison  of  these  two  tests.  The  phenolsulphone- 
phthalein test  indicates  the  function  for  the  moment,  the  blood 
chemical  tests  indicate  the  true  grade  of  the  working  power  of  the 
kidneys. 

"These  experiments  upon  rabbits  represent  the  earliest  definite 
comparative  tests  of  these  two  methods.  The  conclusions  of  Folin 
and  his  collaborators  have  been  well  borne  out  in  practice.  We 
know  that  there  are  many  cases,  with  little  or  no  phenolsulphone- 
phthalein excretion,  that  are  badly  deficient,  and  show  high  re- 
tention of  nonprotein  nitrogenous  blood  constituents;  we  know 
also  that  there  are  some  cases,  with  decreased  phenolsulphone- 
phthalein output,  that  are  functioning  quite  well,  as  judged  by  the 
nonretention  of  these  ingredients  in  the  blood ;  we  also  know  that 
there  may  be  a  normal  phenolsulphonephthalein  output  and  a 
marked  retention  of  the  blood  constituents.  These  three  sets  of 
conditions  would  therefore  make  us  pause  in  accepting  alone  the 
evidences  of  kidney  function  from  the  phenolsulphonephthalein 
test  alone.  Our  personal  experiences  with  a  comparison  of  the 
two  methods  have  forced  us  to  the  conclusion  that  the  estimation 
of  kidney  function,  in  so  far  as  it  interests  the  urologist,  can 
not  be  intelligently  viewed  from  the  standpoint  of  operative  risk 
\vithout  a  survey  of  the  percentage  of  these  blood  constituents, 
as  well  as  the  phenolsulphonephthalein  test.  A  study  of  the 
table  gives  the  detailed  results  of  the  blood  chemical  and  phthalein 


322 


BLOOD   AND    URINE    CHEMISTRY 


.investigations  on  the  series  of  urological  cases  which  we  selected 
for  this  work. 

"A  study  of  these  figures  gives  some  very  interesting  facts.  In 
the  first  place,  Case  No.  1,  of  stricture  of  the  urethra,  at  the  time 
of  the  first  examination,  gave  absolutely  no  evidence,  from  a 

TABLE  XXXIII 

COMPARISON  OF  BLOOD  CHEMICAL  FINDINGS  AND  PHENOLSULPHONEPHTHAL- 
EIN  EXCRETION 


BLOOD 

URINE 

PHTHALEIN  EXCRETION 

Urea 
M 

Uric 
Acid 

Creat- 
inine 

Sugar 

Albu- 

I'hthiil 
ein 

No. 

Name 

Date 

Outcome 

Mgms.  per  100 
c.c. 

Per 

Cent 

min 
* 

Casts 

2  hour 
Out- 
put 

Remarks 

1 

D.I. 

1/25/17 

44 

6.5 

3.93 

0.120 

+ 



None 

Nephritis,  Stricture, 

Sepsis. 

2 

D.I. 

1/27/17 

50 

4.9 

4.39 

0.118 





20 

3 

D.I. 

2/2/17 

63 

4.0 

4.00 

0.171 





Trace 

4 

D.I. 

2/9/17 

'Died'" 

55 

4.9 

3.85 

0.144 





Trace 

5 

R.  C. 

1/26/17 

Died 

20 

4.1 

1.93 

0.118 

. 

. 

41 

Cancer  of  prostate. 

6 

C.S. 

2/2/17 

Improved 

12 

2.5 

1.05 

0.117 

+  + 

Gran. 

37 

Enlargement  of  pros- 

tate. 

7 

R.E. 

2/2/17 

Improved 

12 

2.7 

1.03 

0.090 

+  + 

Gran. 

27 

Enlargement  of  pros- 

tate. 

8 

D.B. 

2/9/17 

Improved 

31 

3.1 

1.97 

0.126 

+++ 

31 

Paraphimosis. 

G.W. 

2/14/17 

Improved 

16 

2.6 

1.15 

.120 



60 

Stricture  of  urethra 

1C 

J.E. 

2/14/17 

Died 

135 

9.9 

5.00 

.200 

Bio 

ody 

None 

Chronic   int.   nephritis 

and  hyper  prostate. 

11 

P.  K. 

2/23/17 

Improved 

12 

2.5 

1.20 

.118 





65 

Phimosis. 

12 

O.M. 

2/24/17 

Unimpr'd 

15 

2.4 

2.06 

.108 



— 

22 

Stricture  of  urethra. 

13 

H.  H. 

2/24/17 

12 

2.9 

2.06 

.111 



— 

47 

Enlarged  prostate. 

Trabeculated  bladder 

14 

R.W. 

2/28/17 

[mproved 

11 

2  7 

1.25 

.105 

. 

. 

69 

Stricture  of  urethra. 

15 

R.W. 

3/21/17 

9 

2.6 

1.16 

.090 



— 

60 

Enlarged  prostate. 

16 

C.W. 

2/28/17 

improved 

25 

5.9 

1.62 

.114 



. 

None 

Stricture  of  urethra. 

17 

J.C. 

2/28/17 

[mproved 

13 

5.7 

1.25 

.108 



— 

40 

Hernia. 

IS 

J.  K. 

2/28/17 

[mproved 

18 

2.0 

1.62 

.108 

. 

— 

31 

Trabeculated  bladder. 

Tabes? 

1!) 

H.  K. 

3/2/17 

[mproved 

11 

3.3 

1.16 

.102 

. 



47 

Stricture  of  urethra. 

20 

R.  B. 

3/2/17 

[mproved 

18 

2.5 

1.70 

.156 



— 

22 

detention  of  urine. 

21 

M.K. 

3/7/17 

Not  oper. 

16 

3.4 

2.15 

.114 

. 

— 

Trace 

Enlargement  of  pros- 

tate. 

22 

L.H. 

3/7/17 

[mproved 

14 

3.5 

1.16 

.114 



_ 

Enlargement  of  pros- 

tate. 

23 

J.D. 

3/8/17 

Operated 

12 

2.5 

1.25 

.120 



— 

50 

Enlargement  of  pros- 

tate. 

24 

W.M. 

3/8/17 

[mproved 

12 

1.2 

1.13 

.117 





48 

schiorectal  abscess. 

25 

R.  H. 

3/21/17 

Improved 

15 

4.4 

1.52 

.096 



— 

21 

Enlargement  of  pros- 

tata. 

if     +  Small  amount. 

-\ — [-Moderate  amount. 
H — | — (-Large  amount. 

clinical  or  urinary  standpoint,  of  any  disturbance  in  the  kid- 
neys. Nevertheless,  when  we  found  44  mgms.  of  urea-nitrogen, 
6.5  uric  acid,  3.93  creatinine,  we  immediately  made  a  serious 
prognosis,  regardless  of  the  fact  that  this  patient  at  this  time 
was  up  and  about  the  hospital  wards,  apparently  in  good  condi- 


BLOOD    CHEMISTRY   AND   NEPHRITIS  323 

tion.  Within  forty-eight  hours  this  patient  went  into  uremia,  at 
which  time  his  blood  findings  were  urea-nitrogen  50,  uric  acid 
4.9,  creatinine  4.39.  At  this  time  a  fatal  prognosis  was  made. 
A  few  days  later  another  examination  showed  more  increase  of 
all  the  ingredients  except  creatinine.  It  is  also  to  be  noted  that 
at  the  time  of  the  first  examination  the  phenolsulphonephthalein 
excretion  was  nil.  At  the  time  of  the  second  examination,  with 
clinical  symptoms  worse,  with  blood  chemical  findings  worse, 
there  was  an  improvement  in  the  phenolsulphonephthalein  out- 
put. Then  there  occurred  a  drop  in  this  figure.  It  might  be  added 
that  this  patient  died  six  weeks  after  the  time  of  the  second  ex- 
amination. In  this  case  the  blood  chemistry  showed  the  true  con- 
dition of  the  patient,  where  clinical  signs  and  urinary  examina- 
tion did  not.  Phenolsulphonephthalein  elimination  also  improved 
in  this  case,  although  the  patient  became  worse.  A  survey  of  the 
complete  figures  of  other  cases  here  shows  that  there  were  a  num- 
ber of  instances,  particularly  in  prostatic  cases,  where  the  blood 
chemical  findings  were  normal,  and  the  phenolsulphonephthalein 
elimination  very  much  decreased.  In  these  cases  the  phenol- 
sulphonephthalein output  was  disregarded  in  surveying  opera- 
.  tive  risk,  the  patient  was  operated,  relying  in  each  case  on  the 
blood  chemical  findings,  convalescence  was  in  no  manner  un- 
usual or  disturbed  by  any  thought  of  kidney  insufficiency,  such 
as  was  indicated  by  the  diminished  phenolsulphonephthalein  out- 
put. 

"We  have  records  here  showing  extensive  changes  in  kidneys 
without  urinary  change,  without  change  in  the  phenolsulphone- 
phthalein output,  and  yet  with  very  definite  retention  of  urea, 
uric  acid  and  creatinine.  We  have  other  data  showing  that  in 
the  presence  of  a  rather  low  phenolsulphonephthalein  output, 
kidney  function  may  be  unimpaired,  so  far  as  retention  of  the 
honprotein  nitrogenous  constituents  is  concerned.  ^ 

' '  The  points  which  we  wish  to  emphasize  from  our  investigations 
with  blood  chemical  methods  as  bearing  especially  upon  surgery, 
do  not  vary  much  from  the  conclusions  that  interest  the  in- 
ternist; namely,  that  the  estimation  of  kidney  function,  after  all, 
is  a  matter  of  computation  of  a  number  of  factors,  and  that  the 
phenolsulphonephthalein  test  occupies  a  subordinate  position, 


324  BLOOD   AND    URINE    CHEMISTRY 

even  when  positive,  and  then  it  is  of  much  more  importance  than 
when  negative. 

"In  other  words,  as  recently  pointed  out  by  Beer:72  'Good 
excretion  of  test  substances  usually  means  good  function.  Oc- 
casionally hyperfunction,  however,  may  accompany  severe  dis- 
eases and  may  be  very  misleading.'  Foster  called  attention  to 
the  high  figures  of  phenolsulphonephthalein  output  in  persons 
dying  with  uremia.  Unfortunately,  the  investigators  who  have 
worked  with  these  Ararious  methods  have  failed  to  make 
sufficiently  searching  researches  upon  all  the  important  blood 
constituents  which  we  are  embracing  in  our  present  work. 
We  have  some  cases  with  mechanical  obstruction  to  the 
outflow  of  urine,  candidates  for  operation,  with  practically 
normal  concentrations  of  uric  acid,  urea  nitrogen,  creatinine  and 
sugar,  and  yet  with  very  low  phenolsulphonephthalein  outputs. 
These  cases  according  to  our  view  in  no  way  were  in  a  state  of 
disordered  kidney  function.  We  have  one  record  of  a  case  of 
marked  stricture  with  no  discoverable  physical  signs  of  kidney 
change,  which  showed  high  concentration  of  these  ingredients, 
including  creatinine,  figures  pointing  to  an  impending  uremia, 
even  though  the  clinical  condition  of  the  patient  at  the  time  of 
the  first  blood  test,  was  extremely  good.  Later  on,  true  to  the 
prediction  of  the  blood  findings,  this  patient  lapsed  into  uremia 
and  dissolution  occurred. 

"The  blood  chemical  analysis  tells  us  what  the  blood  is  storing 
up,  what  the  kidneys  are  doing,  and  what  they  are  not  doing, 
and  also  the  exact  status  of  nitrogenous  and  carbohydrate  equilib- 
rium. 

"We  must  insist  in  emphatically  denying  that  the  estimation 
of  the  presence  and  percentage  of  albumin  in  urine,  and  even 
the  findings  of  casts,  indicate  the  condition  of  the  kidney  func- 
tion. Kidney  disease  and  kidney  function  are  not  synonymous 
by  any  means. 

"From  our  experience  in  this  work  we  believe  these  new  tests 
to  be  a  valuable  addition  to  our  laboratory  methods  in  connection 
with  estimation  of  kidney  fund  ion  before  surgical  operations 
upon  the  genitourinary  tract  and  other  parts  of  the  body." 


"Beer   (Ann.   Surg.    191(),  p.   434) 


BLOOD    CHEMISTRY   AND   NEPHRITIS  325 

One  of  the  most  valuable  and  interesting  communications  on 
the  importance  of  blood  chemical  analyses  to  the  practical  surgeon 
is  that  made  by  Louis  Frank,  F.  A.  C.  S.,  of  Louisville,  Kentucky, 
in  an  address  before  the  St.  Louis  Medical  Society,  as  yet  un- 
published, furnished  us  as  a  personal  communication  by  the  author. 
Frank  discussed  the  subject  under  the  title  "Safety  Factors 
in  Surgery  with  Especial  Reference  to  the  Blood."  The  figures 
are  striking  and  the  remarks  so  timely  that  we  have  decided  to 
include  the  entire  article  in  this  part  of  the  book,  so  that  he  who 
runs  may  read  what  information  a  practising  surgeon  gains  from 
these  routine  tests.  A  surgeon  may  be  a  wonderful  technician,  a 
marvelous  diagnostician,  an  expert  pathologist,  but  unless  he  gives 
heed  to  those  continuous  and  important  processes  going  on  behind 
the  ramparts  which  we  call  physiologic  chemistry,  normal  or  de- 
ranged, his  skill,  his  speed,  his  acumen  will  avail  him  naught  to 
save  his  patient's  life.  The  article  follows: 

"Mr.  J.  H.  J.,  case  No.  19430,  came  under  our  care  February  18,  1919, 
for  an  enlarged  prostate  with  vesical  calculus.  Patient  semiconscious,  un- 
able to  give  history.  Hiccoughing  constantly.  Physical  examination: 
Head,  lungs  and  heart  negative,  odor  uremic.  Prostate  enlarged.  Searcher 
shows  stone  in  bladder.  Urine  ammoniacal.  Eesidual  urine,  two  ounces. 
Bladder  capacity  four  ounces.  From  his  relatives  is  obtained  the  usual 
history  of  a  gradually  increasing  prostatie  disability. 

"Blood  Pressure:     Systolic,   130;   diastolic,  135;   pulse  pressure,  45. 

"Blood  Count:  Hemoglobin,  90%;  erythrocytes,  4,640,000;  leucocytes, 
4,200;  polynuclears,  71%;  lymphocytes  28%;  eosinophiles,  1%. 

"Urinalysis:  Albumin,  present- — triple  phosphates — hyaline  and  granu- 
lar casts.  Eod-shaped  motile  organisms. 

"Pulse  100  to  130.     Temperature  98°  to  99.2°  F. 

"Functional  Tests:     February  19,  1919. 

Phenolsulphonephthalein  First  Specimen  (One  hour)          0% 

Total  Second  Specimen         (Two  and  one- 

half  hours)        2% 

(Two  and  one-half  hours  2% 

Blood  urea  Nitrogen  136        mg.  per  100  c.c.  blood. 

Blood  urea  291.04  mg.  per  100  c.c.  blood. 

Creatinin  2        mg.  per  100  c.c.  blood. 

"February  25,  1919. — Blood  urea  nitrogen,  88  mg.  per  100  c.c..  blood. 
Blood  urea,  188.32  mg.  per  WO  c.e.  blood.  Creatinin,  1.7  mg.  per  100  c.c. 
blood 

"February  2Q,  1919. — Under  local  anesthetic,  Novocaine.  Suprapubic 
cystostomy — large  calculus  removed.  Pezzar  catheter  introduced.  Bladder 
lavage. 

"March  3,  1919. — Blood  urea  nitrogen,  57.7  mg.  per  100.  Blood  urea, 
123.478  mg.  per  100.  Creatinin,  1.25  mg.  per  100. 

"March  11,  1919.— Blood  urea  nitrogen,  30  mg.  per  100.  Blood  urea,  64.2 
mg.  per  100.  Creatinin,  .88  mg.  per  100. 


326  BLOOD   AND   URINE    CHEMISTRY 

"March  17,  1919. — Blood  urea  nitrogen,  20  mg.  per  100.  Blood  urea,  42.8 
mg.  per  100.  Creatinin,  .75  mg.  per  100. 

Phenolsulphonephthalein   first   hour — a   trace;    second   hour — 9.5%. 

"March  24,  1919. — Suprapubic  prostatectomy — gas-oxygen  anesthesia. 
Freyer  tube.  Tube  removed  March  .26.  Irrigations  twice  daily.  March 
29. — Up  in  chair,  eating  well,  mind  clear,  wound  rapidly  closing.  Pulse  and 
temperature  normal.  Recovery. 

"There  must  be  some  explanation  for  the  fact  that  when  two 
patients  with  similar  conditions,  so  far  as  the  usual  examination 
is  concerned,  are  operated  by  two  surgeons  of  equal  skill,  or  per- 
haps the  same  surgeon,  that  one  should  recover  and  the  other  die. 
There  must  also  be  some  explanation  for  the  fact  that  the  man  who 
is  operated  for  appendicitis,  on  the  kitchen  table  of  his  home,  by 
his  family  physician,  who  has  never  before  done  an  appendectomy, 
should  make  an  uneventful  recovery,  while  his  neighbor  dies  after 
the  same  character  of  operation  done  by  a  noted  surgeon  in  one  of 
the  city  hospitals.  Most  certainly  it  was  not  the  skill  of  one  that 
saved  his  patient's  life,  neither  was  it  the  lack  of  skill  of  the  other 
that  was  responsible  for  his  patient's  death;  most  assuredly  one 
patient  had  a  normal  power  of  resistance  through  a  normal  me- 
tabolism and  survived  in  spite  of  the  operation,  and  the  other  with 
lowered  resistance,  the  result  of  a  disturbance  of  metabolism 
(which  could  probably  have  been  foretold  and  the  operation  de- 
layed) died  in  spite  of  the  operation. 

"Since  the  discovery  of  Listerism,  surgery  has  been  busy  per- 
fecting a  technic  which  has  become  so  faultless  as  to  almost  pre- 
clude operative  infection  as  a  cause  of  death.  Rubber  gloves, 
aseptic  ligatures,  well-trained  operating  room  nurses,  and  modern 
hospital  accommodations  have  bred  a  school  of  'operators'  which 
the  laity  and  many  of  the  profession  fail  to  differentiate  from,  and, 
daily  confuse  with  surgeons.  Until  recently  surgeons  have  been 
commendably  occupied  in  unraveling  pathologic  problems  as  ap- 
plied to  the  living  and,  as  a  necessary  incident  thereto,  widening 
most  extensively  the  domain  of  surgical  therapeusis,  and  inciden- 
tally the  opportunities  for  exploitation  of  the  'operator.' 

"We  believe,  however,  that  we  are  in  the  beginning  of  an  era 
which  will  be  marked  by  more  careful  and  extensive  study  of  the 
patient,  not  from  the  standpoint  of  making  out  a  surgical  lesion, 
but  from  the  standpoint  of  his  functional  capacity  to  determine 
his  exact  resistance  and  thus  ascertain  a  scientific  evaluation  of 
the  operability  of  the  individual.  This  will  be  an  epoch  of  physio- 


BLOOD    CHEMISTRY   AND   NEPHRITIS  327 

logic  surgery.  The  work  of  Crile,  Henderson,  and  others  on  shock, 
whether  they  are  right  or  wrong,  the  wrork  of  Fischer  and  others 
has  opened  a  tremendously  wide  field  for  interesting  and  useful 
work.  Stimulating  the  work  of  these  men  was  and  is  the  desire  to 
reduce  mortality  and  as  a  consequence  there  has  developed  a  wider 
and  more  extensive  endeavor  to  estimate  from  the  physiologic  side 
the  factors  which  play  a  part  in  producing  death.  In  these  en- 
deavors we  see  the  true  surgeon,  the  internist,  the  physiologist,  and 
the  pathologist  still  working  hand  in  hand. 

"The  studies  of  Henderson  and  Fischer  on  acidosis,  the  investi- 
gations of  Ambard  and  others  on  renal  function  have  enabled  us 
to  understand  many  factors  we  had  not  previously  reckoned  with, 
which  play  for  or  against  recovery. 

"Despite  the  sphygmomanometer  and  sphygmograph,  notwith- 
standing the  'knocking  at  the  door  by  opportunity'  so  clearly  in- 
dicated in  the  wrork  of  Geraghty  and  Rowntree,  until  within  the 
very  last  few  years  our  preliminary  estimate  of  operability  has 
been  most  perfunctory  and  even  more  valueless.  The  examination 
consisted  of  an  auscultatory  pulmonary  and  cardiac  examination,  a 
routine  red  and  white  count,  and  a  urine  analysis  which  concerned 
itself  merely  with  the  presence  or  absence  of  sugar  and  albumin 
and  renal  derivitives.  These  were  done  casually  by  an  interne  or 
mayhap  an  undergraduate  nurse.  How  farcical ;  but  oh !  what  im- 
portance we  attached  to  them !  Deaths  wre  had,  but  then  they  were 
all  from  shock,  immediate  or  delayed,  maybe  from  iodoform  poison  - 
.ing,  heart  failure,  or  some  other  cause  satisfactory  to  us  and  easy 
of  explanation  to  the  family.  It  took  our  friends  of  the  genito- 
urinary specialty,  led  by  Hugh  Young,  to  awaken  us  to  the  im- 
portance of  the  work  our  confreres  in  physiologic  chemistry  and 
in  medicine  were  doing. 

"Recognizing  the  value  of  this  careful  preliminary  study,  we 
believe  that  today  we  are  able,  barring  the  'uncontrollable  acci- 
dents of  surgery'  to  know  fairly  well  what,  always  in  competent 
hands,  will  be  the  probable  outcome  in  any  given  surgical  case.  I 
say  probable  because  we  are  still  fallable  in  spite  of  our  theoretic 
perfection  of  asepsis,  of  our  knowledge  of  the  burden  the  heart 
may  carry  or  of  the  work  the  kidneys  will  do. 

"The  factors  concerned  in  our  study  vary  quite  likely  in  each 
individual  case  and  in  some  the  preliminary  study  may  be  quite 


328  BLOOD   AND   URINE    CHEMISTRY 

exhaustive,  may  even  be  repeated  time  and  again  along  certain 
lines  before  the  individual  is  deemed  fitted  to  successfully  undergo 
the  operation.  Again  at  times  the  operation  may  be  done  in  more 
than  one  stage  before  the  complete  proposed  procedure  has  been 
carried  out,  having  in  mind  always  the  object  of  all  surgical  thera- 
peutics, namely,  a  living,  well  patient,  rather  than  a  brilliant  op- 
eration and  flowers. 

"We  shall  not  dwell  here  upon  the  routine  blood  and  urine  ex- 
aminations, or  upon  the  chest  examination,  except  to  say  that  no 
patient  with  a  'cold,'  however  slight,  is  ever  subjected  to  anes- 
thesia until  all  evidence  of  rhinitis,  pharyngitis,  or  bronchitis  has 
disappeared.  Our  routine  microscopic  blood  examinations  we  look 
upon  rather  as  diagnostic  than  as  having  bearing  upon  outcome. 

"An  hemoglobinemia  or  marked  anemia  would  necessarily,  ex- 
cept in  a  marked  emergency,  call  for  a  postponement  of  operation 
until  a  more  propitious  finding,  otherwise  a  direct  transfusion  of 
whole  blood  from  a  tested  donor  would  be  carried  out  just  previous 
to  operating.  In  such  cases,  as  in  all  individuals  in  whom  trans- 
fusion is  contemplated,  the  heart  muscle  must  be  carefully  studied 
as  to  the  burden  it  will  carry.  The  weak  heart  muscle  of  the  chronic 
anemic  may  prove  disastrous  under  a  rapidly  increasing  blood 
volume. 

"So  also,  it  is  the  poorly  functionating  heart  rather  than  the 
organically  diseased  organ  which  we  fear  as  an  operative  risk. 
Valvular  heart  lesions  compensated  for  are  not  to  be  considered 
as  bad  risks,  but  the  low  pulse  pressure  heart,  the  myocardium 
weakened,  as  shown  by  a  dilatation  or  failure  to  do  its  work  evenly 
and  properly  under  exercise,  is  to  be  looked  upon,  not  as  a  possible, 
but  as  a  probable,  dangerous  factor.  Practically  all  bad  hearts 
manifest  their  deficiencies  in  the  output  of  the  kidneys.  Therefore 
a  comprehensive  study  of  the  urine.  The  output  of  solids  as  com- 
pared with  the  intake  becomes  of  extraordinary  importance  to  the 
surgeon,  particularly  from  the  standpoint  of  differentiation  be- 
tween heart  and  kidney  disease. 

"Our  genitourinary  friends  taught  us  the  necessity  of  estimating 
the  functional  ability  of  the  kidneys,  but  there  have  been  times 
when  our  simpler  test,  the  phenolsulphonephthalein  test,  seems  to 
have  given  us  little  or  no  information  of  any  value.  Our  reliance 
upon  this  test  alone  led  us  not  infrequently  into  error.  So  we 


BLOOD    CHEMISTRY   AND   NEPHRITIS  329 

turned  to  testing  the  blood  to  determine  the  kidney  function  abil- 
ity from  the  standpoint  of  retention  rather  than  continuing  the 
urinary  study  from  the  excretory  side.  In  this  we  also  found  we 
were  at  times  misled  in  our  interpretations.  As  a  result  we  have, 
within  the  past  two  and  one-half  years,  made  studies  in  our  labora- 
tory not  only  from  the  blood  side,  namely,  of  retention  products, 
but  conjointly  of  the  output  side. 

"We  have  no  desire,  neither  is  it  our  intention,  to  discuss  the 
chemistry  or  physiology  of  the  methods  considered,  but  rather  to 
give  in  a  concise  manner  the  results  of  the  clinical  application  of 
our  work  in  my  own  operative  cases  and  to  other  cases  which  have 
come  under  observation  for  surgical  relief  and  in  which  operative 
therapeusis  was  considered. 

"Many  interesting  facts  were  brought  more  sharply  to  our  no- 
tice in  our  blood  studies  and  these  seemed  to  bear  out  and  prove 
to  our  satisfaction  in  a  practical  way  the  experimental  work  previ- 
ously done  by  others. 

"For  instance  a  factor  to  be  considered  and  which,  we  have 
learned  to  know  is  not  infrequently  the  cause  of  death,  is  that  of 
acidosis.'  I  am  convinced  that  many  of  our  septic  appendicitis 
deaths,  as  well  as  those  following  gall-bladder  surgery  and  other 
types  of  work,  ensue  from  acidosis  rather  than  sepsis  as  they  have 
generally  been  construed. 

"Henderson  has  shown  that  there  must  be  certain  buffer  sub- 
stances in  the  blood  to  prevent  destruction  of  its  alkalinity,  in  fact 
to  maintain  the  blood  at  its  normal  alkalinity.  This  alkalinity  is 
spoken  of  as  the  H-ion  concentration,  and  is  represented  by  a 
logarithmic  notation  of  7  which  in  the  blood  is  very  constant  at 
7.4.  Variations  in  this  concentration  are  of  vastly  more  impor- 
tance than  temperature  or  pulse  variations,  and  a  variation  of  0.2 
in  decrease  means  the  very  greatest  danger  to  the  patient.  We 
know  that  individuals  cannot  live  unless  the  blood  is  alkaline,  and 
any  findings  below  7,  our  notation  number,  means  at  once  acidity 
with  dissolution,  if  it  has  not  previously  occurred.  A  lessening  of 
these  buffer  substances  of  the  H-ion  concentration,  indicates  an 
inability  of  the  blood  to  carry  the  most  abundantly  produced  of 
these  acids,  viz.,  carbonic  acid,  so  that  there  is  loss  of  respiratory 
stimulation,  resulting  in  rapid  diminution  of  lung  ventilation  and 
inability  to  establish  the  normal  equilibrium  of  the  blood. 


330  BLOOD    AND   URINE    CHEMISTRY 

"It  has  been  shown  that  the  administration  of  ether  causes  a 
constant  lowering  of  the  carbonic  dioxide  capacity  of  the  blood 
plasma  and  that  the  degree  of  diminution  is  proportional  to  the 
duration  of  the  anesthesia,  the  maximum  being  attained  at  the 
close  of  the  anesthetic,  without  change  for,  as  a  rule,  a  period  of 
twenty-four  hours.  Herein  we  doubtless  have  the  explanation  of 
many  deaths  without  recovery  from  anesthetic,  in  wrhich  notwith- 
standing the  postoperative  treatment,  fatality  ensues.  What  then 
is  the  remedy  for  this  condition?  How  can  these  patients  best  be 
protected?  The  answer  is  careful  blood  examinations,  the  recog- 
nition of  the  lowered  H-ion  content,  and  the  establishment  of 
treatment  previous  to  the  administration  of  the  anesthetic. 

"Our  tables  studied  in  detail  present  quite  a  number  of  inter- 
esting points  bearing  upon  the  value  of  these  safeguards,  and  our 
preoperative  preparation  with  reference  to  diet,  with  reference  to 
the  anesthetic,  and  the  time  for  operating,  has  constantly  in  mind 
the  chemical  blood  findings. 

"So,  also,  is  the  anesthetic  selected,  keeping  in  mind  the  preced- 
ing facts  and  possibilities ;  in  our  own  work  we  have  given  the 
preference  to  gas-oxygen.  Gas-oxygen  does  not  lessen  the  alkaline 
reserve  in  the  blood,  produces  no  deleterious  effects  upon  the  kid- 
ney, does  not  materially  alter  blood  pressure,  and  is  by  far  the 
safest  anesthetic.  Occasionally  it  is  desirable  that  ether  in  very 
small  quantities  be  mixed  with  the  gas-oxygen,  but  under  such 
circumstances  ether  is  not  given  for  its  anesthetic  effect,  but  as  a 
stimulant.  Under  these  circumstances  and  when  given  in  this  way 
it  becomes  the  most  valuable  circulatory  stimulant  that  we  possess. 

"The  anesthetist  is  also  a  factor  not  to  be  overlooked.  Gas- 
oxygen  may  be  and  is  exceedingly  dangerous  in  the  hands  of  those 
not  trained  in  its  use,  and  not  thoroughly  skilled.  Ether  in  skilled 
hands  is  to  be  preferred  to  gas  in  those  who  have  not  the  highest 
degree  of  efficiency  in  this  particular  mode  of  anesthetic.  The 
danger  in  the  administration  of  ether  is  in  carrying  it  to  the  point 
of  saturation,  as  is  done  by  many  so-called  skilled  anesthetists. 
Under  such  circumstances  acidosis  is  not  infrequently  brought 
about,  and  ether  anesthesia  becomes  a  source  of  the  very,  greatest 
danger. 

"In  not  a  few  cases  of  abdominal  surgery,  the  two-stage  opera- 
tion may  be  a  distinct  advantage,  and  this  is  particularly  true 


BLOOD    CHEMISTRY   AND   NEPHRITIS  331 

in  certain  types  of  suppurating  appendices,  suppurative  gall  blad- 
ders, gastroduodenal  ulcers,  and  in  cancers  involving  various  of 
the  intraabdominal  organs.  The  greatest  field  of  usefulness  for 
the  two-stage  procedures  will  probably  be  found  in  carcinoma  of 
the  stomach  in  those  individuals  who  as  a  result  of  starvation  have 
the  narrowest  margin  between  the  normal  alkaline  condition  of 
the  blood  and  that  of  acidosis  and  in  the  prostatique  with  low 
kidney  function  and  a  high  degree  of  nitrogen  retention  in  the 
blood.  There  is  nothing  in  the  ordinary  urinalysis  to  advise  us  of 
early  metabolic  changes  or  of  early  disturbances  of  renal  function, 
and  here  again  we  must  turn  to  our  blood  study  in  connection  with 
extraordinary  urinary  analysis  or  study. 

"Formerly  much  dependence  was  placed  upon  the  concentration 
of  urea  in  the  urine,  we  know  now  that  a  lowering  of  concentration 
is  often  accompanied  by  an  increased  rate  of  excretion.  In  fact  an 
increase  in  the  quantity  of  urine  may  mean  a  deficiency  in  the  con- 
centrating power  especially  for  nitrogen.73  Whereas  the  normal 
kidney  will  secrete  urine  containing  1.5  per  cent  of  nitrogen,  the 
granular  kidney  may  at  best  attain  .6  or  .7  per  cent.  Success  then 
in  freeing  the  body  of  its  nitrogenous  wastes  is  attained  by  an  in- 
crease in  the  urine.  In  other  words,  where  the  normal  kidney  will 
secrete  1,000  c.c.  of  urine  containing  15  gm.  of  nitrogen,  the  dis- 
eased kidney  will  be  compelled  to  secrete  2500  c.c.  of  urine  with  a 
.6  per  cent  concentration  to  rid  the  system  of  15  gm.  of  nitrogenous 
waste.  It  will  therefore  be  seen  that  a  lowering  of  urea  concentra- 
tion in  the  urine  does  not  necessarily  or  likely  mean  the  retention 
of  nitrogenous  waste  products  in  the  system. 

"We  are  presenting  in  our  chart  a  series  of  surgical  cases  in 
which  the  newer  methods  of  determining  metabolic  disturbances 
and  kidney  function  have  been  applied.  Under  the  medical  cases 
are  many  that  reported  for  some  operative  procedure,  but  upon 
examination  were  found  to  be  unfit  subjects  or  suffered  from  some 
underlying  disturbance,  that  was  more  serious  than  the  condition 
for  which  operation  was  sought. 

"It  is  a  well-known  fact  that  a  disturbance  of  renal  function  is 
a  very  common  accompaniment  of  disease,  particularly  after  the 
age  of  fifty,  and  it.  is  usually  the  degree  of  disturbance  in  the  kid- 
neys that  makes  a  surgical  procedure  more  or  less  hazardous. 


^Foster:     Jour.   Am.  Med.  Assn.,   1916,  b 


332  BLOOD   AND   URINE    CHEMISTRY 

' '  Of  the  methods  for  investigating  renal  function,  none  probably 
have  enjoyed  the  wide  popularity  of  the  phenolsulphonephthalein 
test  of  Rowntree  and  Geraghty.7*  This  method  has  been  applied 
to  a  majority  of  our  cases  and  generally  speaking,  shows  a  close 
agreement  with  other  tests,  but  as  will  be  shown,  it  is  not  infre- 
quently misleading,  and  in  a  few  instances  we  believe  that  a  new 
interpretation  is  needed  for  results  obtained.  We  believe  that 
this  difference  is  due  to  the  fact  that  we  deal  with  the  introduction 
of  a  foreign  substance  into  the  body,  and  its  elimination  cannot 
always  be  compared  to  the  elimination  of  natural  waste  products. 
We  believe,  further,  that  in  a  few  instances  it  acts  as  a  diuretic 
depending  for  this  action  upon  renal  irritation.  We  have  no  other 
way  of  accounting  for  a  case  in  which,  after  the  injection  of  the 
drug  the  two  hour  output  of  urine  was  800  c.c.  and  93  per  cent  of 
the  drug  was  excreted.  The  normal  daily  output  of  urine  in  the 
same  individual  was  1600  c.c.  In  other  words,  after  the  injection 
of  the  drug,  the  first  two  hour  quantity  of  the  urine  amounted 
to  half  the  previous  total  24-hour  output. 

"The  retention  of  nitrogenous  products  in  the  blood  above  cer- 
tain figures75  offers  definite  information  concerning  renal  func- 
tion, provided  wre  are  familiar  \vith  the  nitrogen  intake.  It  has, 
however,  a  negative  value  under  all  circumstances.  Studies  of  the 
urine  and  blood  after  the  intake  of  fluid,  salt  and  nitrogen  lias 
been  carefully  estimated,113  shows  no  definite  relationship  between 
the  retention  of  these  products  and  their  increase  in  the  blood.  The 
retention  of  nonprotein  nitrogen,  urea  nitrogen,  uric  acid,  cre- 
atinin,  etc.,  have  all  been  studied  with  the  idea  of  determining  re- 
nal function.76  In  the  study  of  any  metabolic  process  it  is  always 
necessary  to  study  three  things.  First,  the  food  intake ;  second, 
the  change  which  it  undergoes  in  the  body;  third,  the  excretion  of 
the  waste  products.  A  study  of  any  one  of  these  cannot  give  us 
very  reliable  information.  Ambard77  has  followed  this  principle 
in  his  study  of  renal  function  by  determining  the  maximal  concen- 


ee  and  Geraghty:     Jour.   Pharm.  and   Exper.  Thera] 
7r'Tillotson  and   Comfort:     Arch.   Int.   Med.,   Ixiv,   No.   5,   p.   620. 
Agnew:     Arch.  Int.  Med.,  xiii,  No.   3,  p.   485. 
Hopkins  and  Jones:     Arch.  Int.   Med.,  xv.  No.   6. 
Folin,   Denis  and   Seymour:     Arch.   Int.   Med.,  xvii,   No.   2,   p.   224. 
Schwartz  and  McGill:      Arch.   Int.   Med.,  xvii,  No.   1,  p.   42. 

Folin,   Farmer  and  Denis:     Jour.   Biol.   Chem.,   1912,  xi,  No.   5,  pp.   493,   503,   507,   527. 
Foster:     Arch.   Int.  Med..  xv,   No.  3,  p.  356. 
Meyers  and   Lough:      Arch.    Int.    Med.,   xvi,   No.   4.   p.    536. 
"Mosenthal:     Arch.   Int.    Med.,   xvi,   No.   5,   p.    733. 
"Anibard:     Physiologic    normale   et   pathologique   des   reins,    Paris,    1914. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  333 

tration  power  of  the  kidney.  By  comparing  the  concentration  of 
the  urea  in  the  blood  to  the  rate  of  excretion  in  the  urine,  the  un- 
known factor  is  reduced  to  the  rate  of  blood  flow  through  the  kid- 
ney and  the  functional  activity  of  that  organ.  His  laws  briefly 
stated  are  as  follows:  First,  the  rate  of  urea  outflow  varies  di- 
rectly with  the  square  of  the  concentration  of  urea  in  the  blood, 
if  the  concentration  in  the  urine  remains  constant.  Second,  the 
rate  of  excretion  of  urea  varies  inversely  with  the  square  root  of 
the  concentration  of  the  urea  in  the  urine,  if  the  blood  urea  re- 
mains constant.  The  third  law  combines  the  first  two  and  is  the 
one  generally  in  use  for  the  determination  of  the  constant.  If 
the  concentration  of  the  urea  in  the  blood  and  urine  vary  simul- 
taneously, then  the  rate  of  output  varies  directly  as  the  square  of 
the  concentration  of  urea  in  the  blood  and  inversely  as  the  square 
root  of  that  in  the  urine.  By  adding  correction  factors  for  the 
patient's  weight  and  for  a  standard  urinary  concentration  of  25 
gm.  urea  per  liter  of  urine  he  obtained  an  accurate  working 
formula. 

' '  Cathelin78  opposes  the  adoption  as  being  unreliable  and  Addis 
and  "Watanabe70  have  attempted  to  prove  that  the  rate  of  urea  ex- 
cretion does  not  depend  upon  renal  function.  The  work,  however, 
of  Lewis80  and  others  seems  to  indicate  that  their  contention  is 
wrong.  McLean81  has  substituted  new  figures  for  the  original, 
which  he  calls  the  index  of  urea  excretion.  The  McLean  index  is 
not  given  in  this  series,  but  can  easily  be  applied,  if  desired.  The 
original  coefficient  has  been  determined  in  all  of  the  surgical  cases 
in  this  series,  and  with  very  few  exceptions  has  been  found 
reliable. 

"Acidosis,  the  cause  of  which  has  not  been  definitely  determined 
other  than  that  there  i§  a  general  impoverishment  of  the  body  in 
bases  or  in  substances  which  readily  give  rise  to  bases,82  has  been 
determined  by  estimating  the  hydrogen-ion  concentration  of  the 
blood.83  Other  methods  consist  of  examination  of  the  urine,  a 
study  of  the  products  of  respiration,  and  the  amount  of  alkali  nec- 
essary to  render  the  urine  alkaline  when  administered  by  mouth  or 


"Cathelin:     Folio   Urologica,    1914,    viii,    321. 
"Addis   and    Watanabe:     Jour.    Biol.    Chem.,    1916,    xxiv,    203. 
s°Lewis,  D.  S.:     Arch.  Int.  Med.,  xix,  No.   1,  p.  1. 
"McLean:     Jour.   Exper.   Med.,    1915,   xxii,  p.   212-366. 

Jour.  Am.  Med.  Assn.,  1916,  xxvi,  p.  415. 

s:!Sellards:     Bull.  Johns  Hopkins  Hosp.,    1912,  xxiii,   289;   ibid.,   1914,  xxv,  41. 
s'Levy,   Rowntree  and   Marriott:      Arch.    Int.    Med.,    1915,   xvi,   No.   3. 


334  BLOOD   AND   URINE    CHEMISTRY 

intravenously.  This  latter  method  we  believe  to  be  as  reliable  as 
any,  and  simpler  of  application. 

' '  The  blood  sugar  has  been  estimated  in  most  cases  and  a  hyper- 
gl}*cemia  has  been  the  reason  for  deferring  an  operation  or  for 
selection  of  a  certain  anesthetic  in  a  number  of  cases.  Of  the  nor- 
mal cases  in  this  series,  that  is,  cases  in  which  there  was  no  sus- 
picion of  any  disturbance  of  renal  function,  the  average  for  Am- 
bard's  coefficient  is  .08,  which  agrees  perfectly  with  McLean's81 
figures.  The  average  blood  sugar  in  38  cases  considered  normal 
was  .092  per  cent,  which  is  in  fairly  close  agreement  with  other 
observers. 

"For  the  phenolsulphonephthalein  the  average  excretion  in  nor- 
mal individuals  was  60  +  per  cent.  Our  chart  shows  graphically 
the  relationship  existing  between  the  blood  urea,  Ambard's  con- 
stant and  the  phenolsulphonephthalein  excretion,  hydrogen-ion 
concentration  and  the  salt  and  nitrogen  retention,  where  the  ne- 
phritic test  meal  was  given.  Since  this  paper  and  chart  show  only 
the  value  of  the  various  methods  when  clinically  applied,  no  at- 
tempt shall  be  made  to  account  for  differences  shown  in  the  various 
tests.  Cases  25201,  25120,  25130,  25133  all  show  high  coefficients 
with  the  normal  or  excessive  phenolsulphonephthalein  excretion. 
All  showed  clinically  from  the  urinary  analyses  the  evidence  of 
impairment  of  renal  function,  except  Case  25173  and  in  this  in- 
stance convalescence  following  operation  was  very  stormy,  with 
pronounced  uremic  symptoms.  The  phenolsulphonephthalein  ex- 
cretion in  these  cases  would  seem  to  be  rather  an  unsafe  guide,  un- 
less we  look  upon  figures  above  75  as  indicating  renal  irritation 
and  hyperpermeability  and  this  we  are  inclined  to  do,  particularly 
where  there  is  other  evidence  that  makes  kidney  permeability  ques- 
tionable. It  might  be  contended  that  in  these  few  cases  the  phenol- 
sulphonephthalein excretion  shows  the  true  kidney  function  while 
the  Ambard  constant  was  faulty.  To  which  we  would  reply  that 
the  other  evidence  from  physical  examination  and  the  post-opera- 
tive symptoms  would  indicate  that  the  phenolsulphonephthalein 
excretion  was,  not  an  index  to  the  true  functional  capacity  of  the 
kidney.  Attention  has  previously  been  called  to  such  cases84  and 
the  belief  expressed  that  there  may  be  a  stage  in  nephritis  when 


'Cummings  and  Piness:     Arch.  Int.  Med.,  1917,  xix.  No.  5,  p.  777. 
Pepper   and   Austin:     Am.   Jour.   Med.    Sc.,    1913,    cxlv,   254. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  335 

hyperpermeability  exists,85  at  least,  to  phenolsulphonephthalein 
and  some  other  substances.  We  have  come  to  look  upon  an  output 
of  more  than  75  per  cent  of  the  injected  drug  in  two  hours  as  being 
decidedly  suggestive  of  renal  disturbance  with  irritation  where 
there  is  other  evidence  to  indicate  the  same.  Cases  25010,  25143, 

25190  all  have  normal  coefficients,  but  with  low  phenolsulphone- 
phthalein excretion,  yet  in  all  the  convalescence  was  uneventful. 
It  would  seem  from  this  limited  number  that  a  low  phenolsul- 
phonephthalein excretion  is  not  always  a  contraindication  to  sur- 
gery or  a  true  guide  to  the  functional  capacity  of  the  kidney.   Case 

25191  is  rather   interesting  in  this   connection,   showing   an   in- 
creased constant  with  an  adequate  phenolsulphonephthalein  excre- 
tion at  the  time  of  operation.     Following  operation  convalescence 
was  very  stormy  with  symptoms  of  uremia  pronounced  and  with 
improvement  came  a  decided  lowering  of  the  coefficient,  but  con- 
trary to  what  would  be  expected,  a  decrease  in  the  output  of  phe- 
nolsulphonephthalein.    A  discussion  of  the  reason  for  this  phe- 
nomenon is  out  of  place  here,  but  the  fact  is  significant.     There 
seems  to  be  no  definite  relation  existing  between  the  blood  urea 
and  the  coefficient  of  Ambard.    We  would  particularly  call  atten- 
tion to  Case  25733  which  is  an  exception  to  the  general  rule  and 
also  to  the  law  of  excretion.     Corresponding  to  the  high  blood 
urea  content  with  a  high  urea  constant  was  a  high  urea  concen- 
tration in  the  urine  and  a  greatly  increased  rate  of  output,  thus 
making  a  normal  constant  of  .077.    This  figure  was  misleading  as 
a  prognostic  sign,  since  convalescence  was  very  stormy  and  pre- 
sented decided  uremic  symptoms  for  a  week  or  more.    We  believe 
that  a  high  coefficient  of  Ambard  deserves  great  consideration  even 
in  the  presence  of  a  normal  blood  urea,  but,  on  the  other  hand,  we 
believe  that  a  liigk  Uood  urea  content  is  extremely  significant,  re- 
gardless of  the  constant  or  the  phenolsulphonephthalein  excretion. 
Such  a  combination  will  rarely  occur,  however. 

"There  is  nothing  of  particular  interest  in  regard  to  the  blood 
sugar  in  these  cases  other  than  that  in  a  few  medical  cases  of 
Bright 's  disease,  a  disturbance  of  renal  permeability  for  sugar  is 
shown. 

"In  concluding,  we  would  say  that  generally  speaking  there  is 
a  close  agreement  between  blood  urea,  Ambard 's  constant,  and  the 


•Raetjer:     Arch.  Int.   Med.,  1913,  xi,  593. 


336  BLOOD   AND    URINE    CHEMISTRY 

phenolsulphonephthalein  output.  The  few  exceptions,  so  far  as 
clinical  results  are  concerned,  would  indicate  that  the  coefficient  of 
Ambard  is  of  greater  prognostic  value  than  the  phenolsulphone- 
phthalein excretion,  since  in  the  several  cases  cited  where  the  Am- 
bard constant  was  normal  and  the  phenolsulphonephthalein  output 
was  low,  convalescence  was  uneventful,  and  on  the  other  hand  with 
normal  or  increased  excretion  of  phenolsulphonephthalein  and  in- 
creased constant,  convalescence  was  usually  more  or  less  stormy. 
We  would  furthermore  attach  importance  to  a  phenolsulphone- 
phthalein excretion  above  75  per  cent,  where  there  is  further  evi- 
dence of  disturbed  function.  This  is  particularly  true  of  tubercu- 
lous infection  of  the  kidney. 

"A  high  urea  content  of  the  blood  demands  serious  consideration 
regardless  of  other  tests.  In  this  connection  it  is  well  to  mention 
the  fact  that  Lewis80  has  demonstrated  that  in  cases  of  nephritis 
with  high  blood  ureas  and  high  constant  of  Ambard,  that  while 
the  blood  urea  may  be  reduced  to  practically  normal  by  careful 
diet,  this  decrease  is  accompanied  usually  by  an  increase  in  the 
coefficient,  indicating  no  improvement  so  far  as  function  is  con- 
cerned. 

"From  the  numerous  investigations  concerning  the  condition  of 
acidosis,  renal  function  and  the  retention  of  protein  products  in 
the  blood,  all  of  which  are  determined  for  the  purpose  of  ascertain- 
ing disturbances  of  metabolism,  we  are  justified  in  drawing  the 
following  conclusions :  A  patient  is  not  in  the  best  possible  condi- 
tion to  undergo  any  surgical  procedure  when  he  has — 

"1.  A  hydrogen-ion  concentration  of  his  blood  below  pH  7.35. 

"2.  A  carbon-dioxide  tension  in  the  alveolar  air  below  35. 

"3.  A  soda  tolerance  test  above  15. 

"4.  An  Ambard  coefficient  above  .10. 

"5.  A  urine  which  shows  but  little  variance  in  quantity  from 
day  to  day  and  with  the  specific  gravity  varying  less  than  7  points 
regardless  of  the  intake.  Also  nocturnal  polyuria. 

"G.  A  phenolsulphonephthalein  output  below  40  unless  it  can 
be  accounted  for  by  disease  of  other  organs,  the  liver  particularly. 

"We  feel  that  we  can  best  conclude  this  paper  by  quoting  ver- 
batim from  Koshiro  Nakagawa.80 


M'Nakaga\va,   Koshiro:      I'.rit.   Jour.    Surg.,   iv,    Xo.    15,   p.    386. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  337 

"1.  A  normal  constant  does  not  necessarily  imply  freedom  from 
disease  but  does  indicate  compensation  of  the  renal  defect. 

"  2.  Increased  constant  indicated  impairment  of  function. 

"3.  Particular  diagnostic  significance  in  tuberculous  kidney. 
Normal  constant  suggests  only  one  kidney  affected.  Increased  con- 
stant indicates  both  kidneys  or  that  it  is  associated  with  toxic 
nephritis  of  opposed  kidney. 

"4.  In  disease  of  lower  genitourinary  tract  an  increased  con- 
stant means  impairment  of  renal  function.  This  may  be  due  to 
coexistent  renal  disease  or  to  some  obstructive  or  infective  process 
in  the  lower  urinarj7'  passage.  In  such  cases,  if  the  bladder  is 
drained  a  few  days  before  adopting  more  radical  measures,  and 
the  constant  approaches  normal,  it  would  indicate  purely  secondary 
disturbance  of  kidney,  whereas  if  it  remains  constant,  it  would 
mean  a  gross  kidney  lesion  in  connection  with  other  pathology,  and 
points  out  the  danger  that  may  attend  further  operative  measures. 

"5.  Entails  no  discomfort  to  patient.  Injection  or  ingestion  of 
foreign  substances  is  not  required,  neither  is  it  necessary  to  con- 
trol diet.  It  is  applicable  where  ureteral  catheterization  or  exam- 
ination of  lower  passages  is  impossible. 

"6.  Information  as  to  state  of  renal  function  gained  by  urea  in 
blood  is  amplified  and  completed  by  determination  of  Ambard's 
constant." 

"Methods  Employed 

"Urea  in  Urine  and  Blood:  (Marshall,  E.  K. :  Jour.  Biol. 
Chem.,  1913,  xiv,  283'  and  xv,  487.)  Squibbs'  urease  used.  The 
air  Current  was  used  for  driving  the  ammonia  into  the  acid  solu- 
tion, which  was  nesslerized  and  compared  with  a  standard  ammo- 
nia sulphate  solution  similarly  nesslerized  in  the  colorimeter. 

"Nonprotein  Nitrogen  in  the  Blood:  (Folin :  Jour.  Biol  Chem., 
1912,  Ixi,  No.  5.)  A  combination  of  heat  and  air  current  was  used 
for  transferring  the  ammonia  to  the  acid  solution. 

"Uric  Acid  in  Blood:  Benedict's  method:  Jour.  Biol.  Chem., 
xx,  No.  4. 

"Blood  Sugar:  According  to  Lewis  and  Benedict's  method  as 
modified  by  Myers  and  Bailey,  Jour.  Biol.  Chem.,  1916,  xxiv,  No.  2. 
In  many  instances  both  methods  were  used  and  checked  against 
each  other  and  the  results  were  the  same  in  every  instance.  The 
Myers  and  Bailey  method  was  then  accepted  and  used  throughout. 
A  standard  glucose  solution  was  used  in  place  of  picramic  acid 
solution,  against  which  the  unknown  was  compared. 


338  BLOOD  AND  URINE  CHEMISTRY 

"Hydrogen-ion  Concentration  of  Blood:  (Levy,  Rowntree,  and 
Marriott:  Arch.  Int.  Bed.,  1915,  xvi,  No.  3.) 

"Urine  Examination:  According  to  Mosenthal's  modification 
of  the  Hedinger  and  Schlayer  method,  Arch.  Int.  Med.,  1915,  xvi, 
No.  5.  Deutsch.  Arch.  klin.  Med.,  1914,  cxlv,  120. 

"Sodium  Chloride  Estimation:    Volhardt  method. 

A  recent  study  on  intestinal  obstruction  in  relation  to  the  non- 
coagulable  nitrogen  of  the  blood  is  quite  interesting  along  the  lines 
just  noted.  Cooke,  Rodenbaugh,  and  Whipple87  take  up  the  ques- 
tion of  the  analytical  consideration  of  blood  in  cases  of  intesti- 
nal obstruction,  intestinal  closed  loops,  and  other  acute  intoxica- 
tions. Their  interest  in  this  question  was  aroused  by  a  communica- 
tion of  Tilestoii  and  Comfort,88  who,  in  a  large  series  of  human 
cases,  reported  three  cases  of  intestinal  obstruction  with  very  high 
noncoagulable  nitrogen.  The  present  writers,  Cooke,  Rodenbaugh, 
and  Whipple,  found  that  most  cases  of  intestinal  obstruction, 
especially  with  signs  of  acute  intoxication,  showed  a  high  non- 
coagulable blood  nitrogen,  and  it  seemed  possible  to  them  that  this 
factor  might  be  of  value  in  diagnosis  and  especially  prognosis  of 
acute  abdominal  conditions.  They  have  become  convinced  as  a 
result  of  their  work  that  this  determination  of  nitrogen  in  blood 
is  of  value  in  various  acute  intoxications.  If  the  reading  is  high, 
it  may  be  assumed  that  there  exists  a  dangerous  grade  of  intoxica- 
tion, but  on  the  contrary,  one  may  not  assume  that  a  low  reading 
gives  evidence  of  slight  intoxication,  because  a  fatal  outcome  may 
be  associated  with  a  low  reading.  It  is  therefore  of  considerable 
value  to  know  that  the  noncoagulable  nitrogen  of  the  blood  may 
show  high  readings  in  other  conditions  than  renal  disease.  On 
the  other  hand,  determinations  of  the  blood  urea  alone  are  of 
somewhat  less  value  in  studying  the  retention  products  in  the 
blood  in  these  conditions. 

In  these  animal  experiments  Cooke,  Rodenbaugh,  and  Whipple 
found  that  the  blood  urea  varied  less  than  30  per  cent  to  more 
than  80  per  cent  of  the  total  noncoagulable  nitrogen,  and  while  a 
high  urea  reading  was  the  rule,  the  variations  in  the  urea  curve 
and  the  curves  of  the  other  noncoagulable  nitrogenous  substances 


87Cooke,   Rodenbaugh  and   Whipple:     Jour.   Exper.  Med.,  June,    1916,  vol.   xxiii,  No.   6, 
p.  717. 

""Tileston  and   Comfort:     Arch.    Int.   Med.,    1914,   vol.   xiv,  p.   620. 


BLOOD   CHEMISTRY  AND   NEPHRITIS  339 

were  so  great  that  the  urea  reading  was  a  somewhat  unreliable  in- 
dex of  the  extent  to  which  noncoagulable  nitrogenous  substances 
were  retained.  In  these  experiments  dogs  were  used  mainly,  a  few 
cats  and  one  human  case  being  recorded.  The  blood  was  taken  from 
the  jugular  vein  in  some  cases,  from  the  carotid  in  others.  The 
dogs  were  anesthetized  and  loops  of  the  intestine  tied  off,  the 
animals  watched,  blood  samples  taken  at  various  intervals;  in 
some  cases  the  dogs  were  reoperated,  in  other  cases  they  were  al- 
lowed to  die  of  their  intoxications  due  to  obstruction  operations. 
Besides  the  animal  experimental  observations,  they  record  one  hu- 
man case  of  intestinal  obstruction,  with  blood  findings. 

These  experiments  showed  definite  increase  in  the  noncoagulable 
nitrogen  in  the  blood  of  cases  of  intestinal  obstruction  with  closed 
loops  of  intestine.  With  acute  intoxication,  the  rise  is  shown  as 
striking  and  constant.  This  rise  was  high  and  was  considered  a 
grave  sign  and  was  a  clinical  index  of  a  severe  intoxication  even 
in  spite  of  the  clinical  evidence  to  the  contrary.  But  a  low 
noncoagulable  nitrogen  does  not  guarantee  a  mild  grade  of  in- 
toxication. Acute  proteose  intoxication  in  animals  due  to  the  in- 
jection of  a  pure  proteose  will  show  a  prompt  rise  in  blood  non- 
coagulable nitrogen,  even  an  increase  of  100  per  cent  within  three 
or  four  hours.  These  intoxications  also  showed  a  high  creatinine 
and  urea  concentration.  The  residual  or  undetermined  nitrogen 
was  also  high.  The  human  case  with  autopsy  showed  the  same 
conditions  as  the  animals  under  experiment.  Clinically  the  non- 
coagulable nitrogen  of  the  blood  may  give  information  of  value 
in  intestinal  obstruction.  A  high  reading  indicates  a  grave  con- 
dition, but  a  low  one  may  still  fail  to  show  a  grave  intoxication. 
The  kidneys  in  all  these  cases  at  autopsy  appeared  normal.  It  is 
possible  that  protein  or  tissue  destruction  rather  than  impaired 
eliminative  function  was  responsible  for  the  rise  in  noncoagulable 
nitrogen  of  the  blood  in  these  acute  intoxications.  Transfusions 
of  dextrose  solutions  often  benefit  intestinal  obstruction  and  may 
depress  the  level  of  the  noncoagulable  nitrogen  in  the  blood.  These 
observers  likewise  state  that  some  cases  show  no  change  in  the 
noncoagulable  nitrogen  following  transfusions  and  diuresis,  and, 
as  a  rule,  such  cases  presented  the  most  severe  intoxication. 

Thus,  another  line  of  investigation  was  opened  up  by  this  blood 


340  BLOOD   AND   URINE    CHEMISTRY 

chemical  study  on  intestinal  obstruction.  Perhaps  by  this  kind 
of  research,  the  presence  of  a  severe  and  dangerous  grade  of  sur- 
gical complication  may  be  detected  before  acute  clinical  symptoms 
assert  themselves. 

The  Cholesterol  Content  of  the  Blood 

Considerable  attention  has  been  given  to  the  subject  of  choles- 
terol and  its  diagnostic  importance.  A  few  facts  might  first  be 
stated  as  to  just  what  cholesterol  is:  it  is  a  monatomic,  simple, 
unsaturated,  secondary  alcohol.  It  is  a  substance  found  through- 
out the  human  organism  and  is  a  constituent  of  various  animal 
foods.  Fraser  and  Gardner80  state  that  the  phytosterols  of  the 
plant  foods  are  transformed  to  cholesterol  in  the  body.  It  is  a 
disputed  question  whether  or  not  cholesterol  is  synthetized  in 
the  body.  Lifschiitz90  thinks  that  it  is  formed  from  oleic  acid 
and  also  that  it  holds  some  relationship  to  cliolic  acid,91  since 
the  same  color  reactions  are  obtained  after  oxidation  with  ben- 
zoyl  peroxid.  Goodman92  found  that  cholesterol  injected  directly 
into  the  circulation  appears  to  have  but  slight  influence  on  the 
elimination  of  cholic  acid.  Rosenbloom  and  Gies93  suggests  that 
gallstones  may  arise,  when  among  other  causes,  the  transforma- 
tion into  bile  salts  is  materially  diminished,  with  a  subsequent 
marked  increase  in  the  concentration  of  cholesterol  in  the  bile. 

Cholesterol  occurs  in  the  blood  in  the  free  and  the  combined 
state.  Free  cholesterol  occurs  in  the  corpuscles  and  to  some 
extent  in  the  plasma,  and  the  cholesterol  esters  in  the  plasma 
alone.  Bloor  and  Knudson94  found  in  the  whole  blood  the  average 
percentage  of  cholesterol  in  combination  in  esters  was  about  33.5 
per  cent  and  in  the  plasma  58  per  cent  of  the  total  cholesterol. 
Normally  the  concentration  of  cholesterol  is  the  same  in  plasma 
and  whole  blood.  The  average  found  by  Bloor  was  0.21  per  cent 
for  normal  men  and  0.23  per  cent  for  normal  women.  Gorham 
and  Myers95  state  that  the  figures  of  Bloor  are  too  high  and  that 


""Fraser  and   Gardner:      Proc.    Roy.    Soc.   London    (B)    1910,   vol.    Ixxxii,    p.    559. 
and   Gardner;   Ibid.,   1912,  vol.   Ixxxv,   p.    385. 

""Ufschiitz:     Ztschr.   f.  physiol.   Chem.,   1908,  vol.  Iv,  p.   1. 
"'Lifschiitz:     Ztschr.   f.   physiol.   Chem.,    1914,  vol.   xcii,   p.   383. 
"Goodman:     Beitr.  z.  chem.   Phys.   u.   Path.,   1907,  vol.   ix,  p.  91. 
"Rosenbloom   and    Gies:      Biochem.    Bull.,    1911-12,   vol.    i.    p.    51 
"T.loor   and    Knmlson:     Jour.    Biol.   Chem..    19U>.   vol.   xxix.    p.    7. 
"•••Gorhar 


id    Knudson:  '  Jour.    Biol.   Chem..    1916, 'vol. 'xxix,' p 
and   Myers:      Arch.   Int.   Med.,   1917,   Xo.  4,  p.   599. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  341 

possibly  0.16  or  0.17  per  cent  may  more  nearly  represent  the 
true  value  for  the  cholesterol  of  human  blood. 

Pathologically  a  great  many  conditions  have  been  recorded  in 
which  a  hypercholesteremia  was  found,  for  instance,  arterio- 
sclerosis, nephritis,  diabetes,  especially  with  acidosis,  obstructive 
jaundice,  in  many  cases  of  cholelithiasis,  in  the  early  stages  of 
malignant  tumors  and  in  pregnancy. 

Gorham  and  Myers95  made  cholesterol  estimations  in  the  blood 
of  about  200  subjects  suffering  clinically  from  twenty-five  dif- 
ferent diseases.  Hypercholesterolemia  was  observed  though  not 
invariably,  in  arteriosclerosis,  nephritis,  obstructive  jaundice  and 
diabetes.  A  hypercholesterolemia  was  observed  in  the  cachexia 
of  malignancy  and  all  anemias  of  the  pernicious  type.  The  low 
cholesterol  values  encountered  in  the  blood  plasma  of  patients 
with  pernicious  anemia  were  regarded  by  these  observers  as  of 
considerable  significance,  especially  in  view  of  the  strong  anti- 
hemolytic  action  of  cholesterol. 

On  normal  subjects,  fourteen  in  all,  taken  at  random  and  not 
on  a  special  diet,  the  figures  varied  from  0.13  to  0.19  per  cent. 
Their  average  was  0.15  per  cent  which  compares  very  well  with 
the  data  already  in  the  literature.  In  ten  cases  of  arteriosclerosis, 
the  figures  ran  from  0.16  to  0.26  per  cent,  showing  hyper- 
cholesterolemia. These  figures  compare  well  with  those  already 
given  by  Schmidt.9*  While  we  cannot  trace  the  relationship  be- 
tween hypercholesterolemia  and  arteriosclerosis,  we  do  know 
that  histologic  changes  have  been  noted  in  the  aorta  after  the 
experimental  administration  of  cholesterol. 

In  their  figures  on  nephritis,  while  the  percentages  were  in- 
creased^ there  was  no  apparent  relation  between  the  cholesterol  in 
the  blood  and  the  blood  pressure  or  nitrogen  retention.  Ex- 
cepting the  observation  of  Denis,97  who  found  the  cholesterol 
increased  in  only  one  case  of  nephritis  out  of  a  very  large  series, 
the  observations  of  Gorham  and  Myers  harmonize  with  those  al- 
ready in  the  literature.90- 9S  In  eight  cases  of  diabetes  they  found 

96Schmidt:     The   Clinical    Study   of   Hypercholesterinemia,   Arch.    Int.    Med.,    1914     vol 

xiii,   p.    121. 

B7Denis,   W:     Jour.  Biol.   Chem.,    1917,   vol.    xxix,  p.  93. 

^Chauffard,   Laroche,  and  Grigaut:      Compt.  rend.   Soc.  de  biol.,   1911,  vol.   Ixx,  p     108 
Widal,   Weill  and   Laudat:      Semaine  med.,    1912,  vol.   xxxii,  p.   529. 
Bacmeister   and   Henes:      Deutsch.    med.    Wchnschr.,    1913,    vol.    1,    p.    820. 
Cantieri:     Wien.    klin.    Wchnschr.,    1913,   vol.    xxvi,   p.    1692 
Henes,  E.:     New  York  State  Med.  Jour.,   1915,  vol.  xv,  p.  310. 


342  BLOOD   AND   URINE    CHEMISTRY 

an  increase  in  cholesterol  in  the  blood  of  but  four  cases,  and  these 
four  cases  showed  evidences  of  acidosis.  Since,  as  has  been 
pointed  out  by  Bloor,"  the  cholesterol  increases  along  with  the 
other  lipoids  in  diabetic  lipemia,  the  cholesterol  may  be  taken 
as  an  index  of  the  lipord  content  of  the  blood. 

In  ten  cases  of  cholelithiasis,  one  case  of  the  five  that  were 
confirmed  by  operation,  showed  hypercholesterolemia,  while  in 
the  remaining  five  cases  those  patients  with  an  increased  choles- 
terol in  the  blood  showed  jaundice  clinically.  In  malignancy 
cases  in  the  early  stage  they  found  normal  values  of  cholesterol, 
while  in  advanced  malignant  states  the  values  were  below  normal. 
In  pellagra  they  found  an  increase  in  cholesterol :  it  is  of  interest 
in  this  connection  to  note  the  observation  of  Fischl100  who  found 
the  cholesterol  values  of  the  blood  high  in  the  ordinary  dermatoses 
not  accompanied  by  fever.  On  syphilitics,  patients  with  gastro- 
intestinal conditions  and  miscellaneous  conditions,  the  cholesterol 
values  were  normal.  They  report  three  cases  of  cholesterol  es- 
timations in  pernicious  anemia.  They  found  low  values  in  the 
plasma,  with  normal  figures  for  the  cells,  which  would  appear  to 
be  of  interest  in  this  condition  in  view  of  the  antihemolytic  in- 
fluence of  cholesterol.  The  values  found  in  these  cases  were 
0.061  in  one  case,  0.052  in  another,  0.072  in  the  third.  They  found 
low  values  in  the  plasma  cholesterol  with  normal  figures  in  the 
cellular  cholesterol :  this  they  think  of  great  interest  because  of 
the  antihemolytic  qualities  of  cholesterol.  They  therefore  fed 
cholesterol  to  one  patient  and  noted  clinical  improvement,  in 
harmony  with  the  findings  of  Cantieri.101  Gorham  and  Myers 
concluded  from  their  very  complete  study  of  the  blood  of  200 
subjects  that  the  findings  in  cholelithiasis  are  quite  inconstant. 
Hypercholesterolemia  is  found  in  many  conditions  and  therefore 
its  investigation  in  diseases  of  the  gall  passages  is  of  but  limited 
diagnostic  usefulness.  The  estimation  of  this  substance  may  be 
useful  in  diabetes,  since  cholesterol  serves  as  an  easily  deter- 
mined index  of  any  lipemia. 

Denis  102  made  determinations  of  cholesterol  on  the  blood  of 


TORloor:     Tour.   P.iol.   Chem.,   1916,   vol.   xxvi,  p.   417. 
100Fischl:/Wien.  klin.   Wchnschr.,   1914,  vol.   xxvii,  p.  982. 

101Cantieri:     Rassegrta  Hi   clin.   terap.   e   sc.    affini,   August,    1914,    abstr.,    Central 
chcm.  u.  _Biophyst.  1915,  18,  184. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  343 

twenty  normal  persons  and  of  two  hundred  and  fifty-four  per- 
sons suffering  from  a  variety  of  the  more  common  diseases  and 
including  twelve  in  pregnancy.  As  a  result  of  this  work,  Denis 
concluded  that  in  nephritis,  cardiorenal  disease,  arteriosclerosis, 
and  cardiac  disease  the  blood  cholesterol  remains  at  normal  levels 
both  in  the  early  stages  of  the  disease  and  when  the  patient 
is  practically  moribund.  There  is  no  relation  between  the  non- 
protein  nitrogen  of  the  blood  and  the  cholesterol.  In  syphilis 
it  was  found  that  the  blood  cholesterol  is  not  increased  and  in 
some  cases  it  is  low.  In  twelve  cases  of  pregnancy  no  increase  in 
blood  cholesterol  was  noted.  In  twenty-five  diabetics,  five  showed 
a  slight  increase  in  the  cholesterol  content  of  the  blood.  This 
hypercholesterolemia  bore  no  constant  relation  to  the  blood  sugar 
or  to  the  acetone  bodies  or  sugar  in  the  urine.  In  the  case  of 
the  acute  infections,  typhoid  fever,  pneumonia,  pleurisy,  and  rheu- 
matic fever,  low  cholesterol  values  were  found  when  the  patient 
was  very  ill;  in  convalescence  normal  values  were  established. 
In  nine  cases  of  gallstone  disease  no  marked  increase  of  blood 
cholesterol  Avas  noted.  In  icterus  even  when  severe  there  was 
no  increase.  In  cirrhosis  of  the  liver  the  values  were  within 
the  lower  normal  limits.  In  fourteen  cases  of  malignant  disease 
the  cholesterol  figures  were  normal  except  in  one  case  associated 
with  anemia  in  which  the  value  was  low.  In  diseases  of  the 
skin  the  blood  cholesterol  figures  obtained  were  within  normal 
limits.  In  severe  primary  and  secondary  anemias  subnormal 
values  were  obtained.  No  definite  relation  was  found  to  exist 
between  the  number  of  corpuscles  or  hemoglobin  percentage  and 
cholesterol  values.  In  severe  hyperthyroidism  figures  were  ob- 
tained within  or  just  below  the  lower  normal  limit.  In  one  case 
of  myxedema  a  cholesterol  figure  slightly  above  the  highest  nor- 
mal value  was  found.  In  but  a  few  cases  of  diabetes  was  hy- 
percholesterolemia seen,  and  inasmuch  as  low  cholesterol  values 
are  not  characteristic  of  any  special  pathologic  condition,  Denis 
believes  that  cholesterol  determinations  in  the  blood  are  at  pres- 
ent of  no  value  in  the  clinical  diagnosis  or  prognosis  of  disease. 
These  conclusions  are  practically  those  of  Gorham  and  Myers 
except  that  Gorham  and  Myers  believe  the  estimations  in  diabetes 
may  be  of  value:  on  this  point  Denis  radically  differs. 


344  BLOOD   AND   URINE    CHEMISTRY 

The  work  of  Rothschild  and  Felsen,103  and  their  conclusions  are 
not  at  all  in  accord  with  the  above  observations  of  Gorham  and 
Myers.  They  had  previously  shown104  that  a  number  of  patients 
with  cholelithiasis  had  a  continuous  hypercholesterolemia.  Even 
after  operation  at  which  all  causes  for  an  obstructive  hyper- 
cholesterolemia had  been  removed,  these  patients  again  became 
hypercholesterolemic  with  no  discoverable  basis  for  the  condition. 
They  believe  that  the  liver  is  the  regulator  of  the  cholesterol 
metabolism  of  the  bod}-,  the  cholesterol  being  kept  at  a  more  or 
less  constant  level  by  excretion  of  cholesterol  through  the  bile. 
In  their  last  communication  these  observers  contend  that  in  ob- 
structive icterus  due  to  stones,  the  cholesterol  content  of  the 
blood  is  markedly  elevated  and  bears  a  definite  relationship  to 
the  intensity  of  the  icterus.  They  also  conclude  that  in  conditions 
associated  with  hepatic  disorders,  the  cholesterol  content  of  the 
blood  is  not  increased,  and  is  usually  reduced.  The  choles- 
terinemia  is  not  proportionate  to  the  amount  of  bile  pigments 
present  in  the  blood.  In  the  so-called  hemolytic  icterus  they  found 
no  increase  of  blood  cholesterol.  They  found  in  obstructive 
jaundice  amounts  of  cholesterol  as  high  as  700  mgms.  per  100 
c.c.  of  blood.  They  found  that  a  patient  with  jaundice  and  high 
temperature  and  an  infection,  will  have  a  lower  cholesterol  con- 
tent than  a  patient  with  the  same  degree  of  jaundice,  but  with 
no  active  infection.  It  is  interesting  to  note  that  these  observers 
found  the  blood  low  in  cholesterin  in  three  cases  of  acute  yellow 
atrophy  of  the  liver. 

Lipemia 

It  is  of  considerable  interest  to  know  something  of  the  amount 
of  fat  or  lipoids  in  the  blood  during  diabetic  investigations.  These 
accumulations  in  diabetes  are  well  known  and  indicate  pathologic 
changes  of  highest  import  to  the  clinician.  This  has  been  already 
alluded  to  in  our  remarks  upon  acidosis.  In  addition  to  this  con- 
dition, we  might  mention  the  interesting  work  of  Bloor  and  Mac- 
Pherson105  on  the  blood  lipoids  in  anemia.  Since  the  characteristic 
features  of  anemia  and  pernicious  anemia  are  destructive  changes 
in  the  red  cells,  attention  has  been  called  to  the  hemolytie  and 


""Rothschild  and   Felsen:     Arch.  Int.  Med.,   Nov.   15,   1919,  vol.   xxiv,  No.   5,  p.   520. 
""Rothschild   and   Rosenthal:     Am.   Jour.   Med.    Sc.,    September,    1916,   vol.   clii,   p.   394. 
103Bloor  and  MacPherson:     Jour.   Biol.   Chem.,   1917,  vol.  xxxi,  p.  79. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  345 

the  antihemolytic  substances,  particularly  to  blood  lipoids. 
The  work  of  Gorham  and  Myers  indicated  their  findings  in 
pernicious  anemia  in  respect  of  cholesterol.  Berger  and 
Tsuchiya106  reported  that  the  ether  extract  of  the  intestinal  mucosa 
of  a  patient  dead  with  pernicious  anemia  had  several  times  greater 
hemolytic  power  than  that  of  normal  mucosa.  McPhedran107 
failed  to  substantiate  this  report.  Faust  and  Tallquist108  found 
hemolytic  lipoids  in  the  pancreas  and  gastrointestinal  mucosa 
of  persons  not  suffering  with  anemia.  Kullmaiin109  and  later 
Faust  and  Tallquist108  found  that  the  lipoids  of  cancer  tissue  were 
hemolytic.  Considerable  work  has  been  done  on  the  lipoids  in 
anemia  due  to  the  Bothriocephalus  latus.  In  1888  Schapiro110  de- 
scribed a  form  of  anemia  due  to  this  worm.  Tallquist111  demon- 
strated hemolytic  lipoids  in  this  worm  and  later  with  Faust109 
isolated  the  hemolytic  substance  which  was  cholesterol  oleate. 
They  found  the  oleic  acid  was  the  hemolytic  substance.  Faust 
found  that  long  continued  administration  of  oleic  acid  to  dogs 
and  rabbits  gave  rise  to  anemia  conditions.  Since  the  hemolytic 
agent  in  all  these  experiments  was  the  unsaturated  fatty  acids, 
it  appears  that  toxic  quantities  of  these  acids  enter  the  blood 
by  way  of  the  chyle.  There  are  three  explanations  for  the  anemia 
brought  about  by  long  continued  feeding  with  unsaturated  fats: 
abnormality  of  the  absorptive  mechanism,  allowing  certain 
amounts  of  hemolytic  lipoids  to  reach  the  blood;  failure  of  the 
assimilative  mechanism  in  the  blood  or  tissues  resulting  in  an 
abnormal  accumulation  of  these  substances  either  free  or  in  the 
form  of  toxic  derivatives ;  or,  a  decrease  in  the  hemolytic  sub- 
stances in  the  blood. 

Cholesterol  and  lecithin  have  been  shown  to  act  antagonisti- 
cally in  certain  types  of  hemolysis  (by  cobra  venom)  ;  both  are  be- 
lieved to  take  an  active  part  in  fat  metabolism.  However,  but 
little  attempt  has  been  made  to  study  these  substances  in  rela- 
tion to  anemia.  Bloor  and  MacPherson  therefore  undertook  an 
investigation  along  these  lines,  mostly  on  patients  with  pernicious 
anemia,  with  a  few  cases  of  secondary  anemia  including  one  from 


°«Berger   and   Tsuchiya:     Deutsch.   Arch.   klin.   Med.,    1909,  vol.   xcvi,   p.   252 

"•McPhedran:     Jour.   Exper.    Med.,    1913,  vol.   xvii,  p.   527. 

osFaust  and  Tallquist:      Arch.  exp.   Path.   u.   Pharm.,   1907,  vol.  Ivii,  p.   367. 

""Kullmann:     Ztschr.,  f.   klin.   Med.,   1904,  vol.   liii,   p.  293. 

10Schapiro:     Ztschr.,   f.   klin.   Med.,    1888,  vol.  xiii,   p.    416. 

"Tallquist:     Ztschr.,  f.  klin.  Med.,   1907,  vol.  Ixi,  p.  427. 


346  BLOOD   AND   URINE    CHEMISTRY 

Bothriocephalus  latus.  They  found  that  the  blood  lipoid  values 
in  anemia  were  normal  or  nearly  so,  as  long  as  the  percentage 
of  blood  corpuscles  remained  above  half  the  normal  value.  When 
the  percentage  dropped  below  this  level,  abnormalities  appeared 
which,  in  the  order  of  their  magnitude  and  also  of  the  frequency 
of  their  occurrence  were  (1)  high  fat  in  the  plasma,  (2)  low 
cholesterol  in  the  plasma  and  occasionally  in  the  corpuscles,  and 
(3)  low  lecithin  in  the  plasma.  The  lipoid  composition  of  the 
corpuscles  was  found  to  be  normal  in  almost  all  cases.  There  was 
therefore  nothing  in  their  composition  to  indicate  abnormal  sus- 
ceptibility to  hemolysis.  In  their  studies  on  splenectomy  cases, 
six  in  all  which  were  studied  by  them,  they  found  increased  total 
fatty  acids  and  lecithin  in  the  corpuscles  and  of  cholesterol  in 
the  plasma.  The  results  were  the  same  whether  the  patients  had 
anemia  or  not.  The  relation  between  free  and  bound  cholesterol 
was  found  to  be  within  the  normal  limits  in  all  cases  of  anemia 
except  the  two  cases  in  which  there  was  carcinoma,  thus  giving 
little  support  to  the  assumption  that  an  abnormally  great  com- 
bination of  cholesterol  as  ester  is  a  factor  in  the  production  of 
anemia.  The  IOAV  values  for  lecithin  and  the  high  values  for  fat 
which  were  generally  most  marked  in  these  cases  where  the  blood 
corpuscles  percentages  were  lowest  are  regarded  as  due  to  defi- 
cient fat  assimilation  in  the  blood  resulting  from  the  lack  of  suffi- 
cient corpuscles  to  bring  about  the  change  of  fat  to  lecithin  which 
has  been  found  to  be  one  function  of  the  corpuscles.  While  the 
results  offer  no  certain  evidence  that  abnormalities  in  the  blood 
lipoids  are  responsible  for  anemia,  the  low  values  for  cholesterol, 
which  is  an  antihemolytic  substance,  and  the  high  fat  fraction, 
which  may  indicate  the  presence  of  abnormal  amounts  of  hemo- 
lytic  lipoids  in  the  blood,  are  possible  causative  factors  which 
the  writers  believe  may  be  proved  by  subsequent  investigations. 
Bloor  continuing  his  work  on  blood  lipoids  has  studied  the 
facts  of  lipemia  in  connection  with  nephritis.112  Previous  workers 
have  found  fat  disturbances  in  connection  with  this  disease. 
Thus  Watjoff113  found  in  a  case  of  nephritis  microscopically  visi- 
ble fat  which  stained  with  osmic  acid.  Bocnniger114  reported  fat 

"2Rloor:     Jour.   Biol.   Chem.,   1917,  vol.   xxxi,  p.   575. 
113Watjoff:     Deutsch.  med.  Wchnschr.,   1897,  vol.   xxiii,  p.  559. 
"4Boenniger:     Ztschr.,  f.  klin.  Med.,  1901,  vol.  xlii,  p.  65. 


BLOOD    CHEMISTRY   AND   NEPHRITIS  347 

high.  Erben115  showed  increased  values  for  fat  and  lecithin  in 
a  suhchronic  case.  Greenwald116  found  high  lipoid  phosphorus 
in  some  of  his  nephritics.  Chauffard,  La  Roche  and  Grirgaut117 
found  hypercholesterolemia  in  chronic  nephritis  with  milky 
plasma  in  a  case  of  uremia,  and  Widal,  Weill  and  Laudat118  found 
lipemia  frequently  in  nephritis.  Henes119  found  the  cholesterol  in 
blood  increased  the  most  in  the  severest  cases.  Mueller106  found 
high  lipoid  values  in  a  case  of  nephritic  lipemia.  Schmidt120 
found  the  cholesterol  values  high  in  hypertension,  when  the  kid- 
ney function  was  disturbed.  Epstein  and  Rothschild121  found  the 
blood  lipoids  high  in  chronic  parenchymatous  nephritis.  They 
found  the  lipoids  diminished  in  uremic  cases.  Denis122  found 
an  increase  of  cholesterol  in  the  blood  in  but  one  case  of  nephritis 
out  of  fifty  examined.  Bloor's  figures  are  based  upon  an  analysis 
of  samples  taken  before  breakfast  so  as  to  exclude  alimentary 
lipemia  and  these  samples  were  treated  at  the  hospital  with 
alcohol-ether  as  soon  as  obtained  to  obviate  changes  produced  by 
standing.  He  found  that  the  abnormalities  in  the  blood  lipoids 
in  severe  nephritis  were  found  to  be  high  fat  in  plasma  and  cor- 
puscles and  high  lecithin  in  the  corpuscles.  The  cholesterol  values 
were  practically  normal.  These  abnormalities  he  found  were  the 
same  as  those  found  in  alimentary  lipemia  and  for  this  reason 
are  regarded  as  a  result  of  a  retarded  assimilation  of  fat  in  the 
blood,  which  in  turn  is  thought  to  be  one  manifestation  of  a 
general  metabolic  disturbance  brought  about  by  a  lowered  "al- 
kali reserve"  of  the  blood  and  tissues. 


13Krben:     Ztschr.,   f.   klin.    Med.,    1903,    1,   441. 

16Greenwald:     Jour.  Biol.   Chem.,   1915,  vol.  xxi,  p.   29. 

1TChauffard,   I.aRoche,   Girgaut:     Compt.   rend.    Soc.   de  biol.,   1911,  vol.   Ixx,   p. 

lsWidal,   Weill,    Laudat:     Semaine  med.,    1912,   vol.   xxxii,   p.    529. 

"Henes:     Deutsch.  Arch.   f.  klin.  Med.,   1913,  vol.  cxi,   p.  122. 
120Mueller:     Ztschr.    f.   physiol.    Chem.,    1913,  vol.      Ixxxvi,   p.   469. 
•"Schmidt:     Arch.   Int.  Med..   1914,  vol.  xii,  p.   121. 
^Epstein  and   Rothschild:     Jour.   Biol.   Chem.,    1917,  vol.   xxix,   p.   4. 
123Denis:     Jour.  Biol.   Chem.,   1917,  vol.   xxix,  p.   93. 


CHAPTER  XXXI 

BASAL  METABOLISM 

While  the  subject  of  basal  metabolism  properly  belongs  to  the 
field  of  physiologic  chemistry,  still  the  widespread  interest  in  this 
subject  from  the  standpoint  of  clinical  medicine  has  induced  us 
to  add  a  few  words  for  the  benefit  of  those  who  are  taking  up  this 
question  as  an  aid  to  diagnosis. 

It  promises  to  open  up  some  remarkably  interesting  and  valua- 
ble paths  in  the  domain  of  clinical  diagnosis. 

Metabolism. — It  might  be  well  to  briefly  review  some  of  the 
well  known  facts  on  metabolism  before  considering  the  methods 
of  analysis.  We  know  that  food  is  taken  into  the  gastrointestinal 
canal,  there  prepared  for  absorption,  and  thence  carried  to  the 
tissues  either  to  be  directly  consumed  or  else  to  be  stored  away. 
Waste  products  are  formed  and  excreted  from  the  body.  By  com- 
parison of  the  products  excreted  with  those  taken  in  as  food,  we 
know  how  much  is  retained  or  lost.  This  constitutes  general  metab- 
olism. Special  metabolism  entails  the  study  of  the  chemical 
changes  which  each  of  the  foodstuffs  undergo  in  passing  through 
the  phases  of  absorption  and  excretion. 

In  estimating  the  figures  on  general  metabolism  we  must  compare 
the  same  substances  that  are  found  in  the  intake  and  the  output. 
These  are  multitudinous.  From  an  elementary  standpoint,  ther,c 
are  only  two  substances  which  we  can  compare,  namely  oxygen  and 
nitrogen.  Yet  an  estimation  of  these  two  elementary  substances 
in  intake  and  output  will  furnish  us  much  information  concerning 
the  fate  of  protein,  fat,  and  carbohydrates  in  the  body. 

There  are  certain  terms  used  in  connection  with  metabolic  work 
which  must  be  explained.  First,  energy  'balance,  which  is  a  com- 
parison of  the  actual  energy  which  an  animal  expends  with  the 
energy  rendered  available  by  metabolism. 

For  a  full  discussion  of  the  subject  of  metabolism  and  the 
methods  now  in  vogue  of  estimating  it,  we  are  indebted  to  Dr. 
J.  J.  E,  Macleod  from  whose  excellent  work,  Physiology  and 

348 


BASAL    METABOLISM  349 

Biochemistry  in  Modern  Medicine,  the  following  quotations  and  il- 
lustrations are  taken  : 

"ENERGY  BALANCE 

"The  unit  of  energy  is  the  large  calorie  (written  C.),  which  is 
the  amount  of  heat  required  to  raise  the  temperature  of  one  kilo- 
gram of  water  through  one  degree  (Centigrade)  of  temperature.* 
We  can  determine  the  calorie  value  by  allowing  a  measured  quan- 
tity of  a  substance  to  burn  in  compressed  oxygen  in  a  steel  bomb 
placed  in  a  known  volume  of  water-  at  a  certain  temperature. 
Whenever  combustion  is  completed,  we  find  out  through  how  many 
degrees  the  temperature  of  the  \\7ater  has  become  raised  and  multi- 
ply this  by  the  volume  of  water  in  liters.  Measured  in  such  a 
calorimeter,  as  this  apparatus  is  called,  it  has  been  found  that  the 
number  of  calories  liberated  by  burning  one  gram  of  each  of  the 
promixate  principles  of  food  is  as  follows: 


Protein     ...........................   5.0 

Fat    ...............................   9.3 

"The  same  number  of  calories  will  be  liberated  at  whatever  rate 
the  combustion  proceeds,  provided  it  results  in  the  same  end  prod- 
ucts. When  a  substance,  such  as  sugar  or  fat,  is  burned  in  the  pres- 
ence of  oxygen,  it  yields  carbon  dioxide  and  water,  which  are  also 
the  end  products  of  the  metabolism  of  these  footstuffs  in  the  animal 
body;  therefore,  when  a  gram  of  sugar  or  fat  is  quickly  burned 
in  a  calorimeter,  it  releases  the  same  amount  of  energy  as  when 
it  is  slowly  oxidized  in  the"  animal  body.  But  the  case  is  different 
for  proteins,  because  these  yield  less  completely  oxidized  end  prod- 
ucts in  the  animal  body  than  they  yield  when  burned  in  oxygen; 
so  that,  to  ascertain  the  physiological  energy  value  of  protein,  we 
must  deduct  from  its  physical  heat  value  the  physical  heat  value  of 
the  incompletely  oxidized  end  products  of  its  metabolism.  It  is 
obvious  that  we  can  compute  the  total  available  energy  of  our 
diet  by  multiplying  the  quantity  of  each  foodstuff  by  its  calorie 
value. 

*The  distinction  between  a  calorie  and  a  degree  of  temperature  must  be  clearly  un- 
derstood. The  former  expresses  quantity  of  actual  heat  energy;  the  latter  merely  tells 
us  the  intensity  at  which  the  heat  energy  is  being  given  out. 


350 


BLOOD   AND   URINE   CHEMISTRY 


"Methods. — In  order  to  measure  the  energy  that  is  actually 
liberated  in  the  animal  body,  we  must  also  use  a  calorimeter,  but 
of  somewhat  different  construction  from  that  used  by  the  chemist, 
for  we  have  to  provide  for  long-continued  observations  and  for 
an  uninterrupted  supply  of  oxygen  to  the  animal.  Animal  calorim- 
eters are  also  usually  provided  with  means  for  the  measurement 
of  the  amounts  of  carbon  dioxide  (and  water)  discharged  and  of 


Fig.  67. — Respiration  calorimeter  of  the  Russell  Sage  Institute  of  Pathology,  Rellevue 
Hospital,  New  York.  At  the  right  is  seen  the  table  with  the  absorption  tubes;  and  in  the 
middle,  at  the  back,  the  electric  control  table  for  regulating  the  temperature  of  the 
double  walls  cf  the  calorimeter.  At  the  extreme  left  is  the  oxygen  cylinder.  (Lusk's 
Science  of  Nutrition.) 

oxygen  absorbed  by  the  animal  during  the  observation.  Such 
respiration  calorimeters  have  been  made  for  all  sorts  of  animals, 
the  most  perfect  for  use  on  man  having  been  constructed  in  Amer- 
ica (see  Fig.  67).  As  illustrating  the  extreme  accuracy  of  even 
the  largest  of  these,  it  is  interesting  to  note  that  the  actual  heat 
given  out  when  a  definite  amount  of  alcohol  or  ether  is  burned  in 
one  of  them  exactly  corresponds  to  the  amount  as  measured  by  the 


BASAL   METABOLISM  351 

smaller  bomb-calorimeter.  All  of  the  energy  liberated  in  the  body 
does  not,  however,  take  the  form  of  heat.  A  variable  amount  ap- 
pears as  mechanical  work,  so  that  to  measure  in  calories  all  of  the 
energy  that  an  animal  expends,  one  must  add  to  the  actual  cal- 
ories given  out,  the  calorie  equivalent  of  the  muscular  work  which 
has  been  performed  by  the  animal  during  the  period  of  observation. 
This  can  be  measured  by  means  of  an  ergometer,  a  calorie  corre- 
sponding to  425  kilogram*  meters  of  work.  That  it  has  been  possi- 
ble to  strike  an  accurate  balance  between  the  intake  and  the  output 
of  energy  of  the  animal  body,  is  one  of  the  achievements  of  modern 
experimental  biology.  It  can  be  done  in  the  case  of  the  human  ani- 
mal •  thus,  a  man  doing  work  on  a  bicycle  ergometer  in  the  Benedict 
calorimeter  gave  out  as  actual  heat  4,833  C.,  and  did  work  equalling 
602  C.,  giving  a  total  of  5,435  C.  By  drawing  up  a  balance  sheet 
of  his  intake  and  output  of  food  material  during  this  period,  it 
was  found  that  the  man  had  consumed  an  amount  capable  of 
yielding  5,459  C.,  which  may  be  considered  as  exactly  balancing  the 
actual  output. 

"It  would  be  out  of  place  to  give  a  full  description  of  the  res- 
piration calorimeter  here.  The  general  construction  will  be  seen 
from  the  accompanying  figure  of  the  form  of  apparatus  in  use 
for  patients  in  the  Russell  Sage  Institute,  New  York.  One  of  the 
most  interesting  details  of  its  construction  concerns  the  means  taken 
to  prevent  any  loss  of  heat  from  the  calorimeter  to  the  surround- 
ing air.  This  is  accomplished  in  the  following  way:  The  inner- 
most layer  of  the  wall  is  of  copper ;  then,  separated  from  this  by  an 
air  space,  is  another  wall  of  copper,  outside  of  which  are  two 
wooden  walls  separated  from  each  other  and  from  the  outer  copper 
walls  by  air  spaces.  The  two  copper  walls  are  connected  through 
thermoelectric  couples,  so  that  an  electric  current  is  set  up  when- 
ever there  is  any  difference  in  their  temperatures.  The  current 
is  observed  by  means  of  a  galvanometer  placed  outside  the  calorim- 
eter, and  from  its  movements  the  observer  either  heats  up,  or  cools 
down  the  outer  copper  walls  so  as  to  correct  the  difference  of  tem- 
perature causing  the  current.  This  is  done  by  an  electric  heating 
device  or  by  cold  water  tubes  placed  between  the  outermost  copper 
and  the  innermost  wooden  walls.  Since  the  temperature  of  the  two 

*A  kilogram  meter  is  the  product  of  the  load  in  kilograms  multiplied  by  the  distance 
in  meters  through  which  it  is  lifted. 


352  BLOOD    AND    URINE    CHEMISTRY 

copper  walls  is  the  same,  there  can  be  no  exchange  of  heat  between 
them,  and  consequently  none  of  the  heat  that  is  absorbed  by  the  in- 
ner copper  walls  is  allowed  to  be  carried  away.  All  the  heat  given 
out  by  the  animal  is  absorbed  by  the  stream  of  cold  water  flowing 
through  the  coils  of  pipe  in  the  chamber.  The  heat  used  to 
vaporize  the  moisture  from  skin  and  lungs  must  of  course  also  be 
measured.  This  is  done  by  collecting  the  water  vapor  in  a  sul- 
phuric-acid bottle  placed  in  the  ventilating  current.  By  inulli- 
plying  the  grams  of  water  by  the  factor  for  the  latent  heat  of 
vaporization,  we  obtain  the  calories  of  heat  so  eliminated. 

"  'The  calorimeter  contains  a  comfortable  bed  and  is  provided 
with  two  windows,  a  shelf,  a  telephone,  a  fan,  a  light,  and  a  Bowles 
stethoscope  for  counting  the  pulse.  The  ordinary  experiment  takes 
about  as  long  as  a  trip  from  New  York  to  New  London.  Patients, 
as  a  rule,  doze  from  time  to  time  or  else  try  to  work  out  some 
scheme  by  which  they  can  amuse  themselves  without  moving.  Af- 
ter three  or  four  hours  they  are  rather  bored  by  the  quiet,  and 
the  observations  are  not  prolonged  beyond  this  time.  They  are 
allowed  to  turn  over  in  bed  once  or  twice  an  hour,  but  reading 
and  telephoning  are  discouraged,  since  these  increase  the  metab- 
olism. The  air  in  the  box  is  fresh  and  pure,  the  patient  suffers 
no  discomfort,  and  objections  to  the  procedure  arc  very  infrequent. 
Most  of  the  patients  are  only  too  glad  of  the  extra  attention,  and 
they  insist  that  the  calorimeter  has  a  marked  therapeutic  value.' 
(Du  Bois.) 

"Normal  Values. — Having  thus  satisfied  ourselves  as  to  the  ex- 
treme accuracy  of  the  method  for  measuring  energy  output,  wre 
shall  now  consider  some  of  the  conditions  that  control  it.  To  study 
these  we  must  first  of  all  determine  the  basal  heat  production — 
that  is,  the  smallest  energy  output  that  is  compatible  with  health. 
This  is  ascertained  by  allowing  a  man  to  sleep  in  the  calorimeter 
and  then  measuring  his  calorie  output  while  he  is  still  resting  in 
bed  in  the  morning,  fifteen  hours  after  the  last  meal.  When  the 
results  thus  obtained  on  a  number  of  individuals  are  calculated 
so  as  to  represent  the  calorie  output  per  kilogram  of  body  weight 
in  each  case,  it  will  be  found  that  1  C.  per  kilo  per  hour  is  dis- 
charged— that  is  to  say,  the  total  energy  expenditure  in  24  hours 
in  a  man  of  70  kilos,  which  is  a  good  average  weight  will  be  70  X 
24  =  1,680  C. 


BASAL    METABOLISM  353 

' '  When  food  is  taken  the  heat  production  rises,  the  increase  over 
the  basal  heat  production  amounting  for  an  ordinary  diet  to  about 
10  per  cent.  Besides  being  the  ultimate  source  of  all  the  body  heat, 
food  is  therefore  a  direct  stimulant  of  heat  production.  This  spe- 
cific dynamic  action,  as  it  is  called,  is  not,  however,  the  same  for  all 
groups  of  foodstuffs,  being  greatest  for  proteins  and  least  for 
carbohydrates.  Thus,  if  a  starving  animal  kept  at  33°  C.  is  given 
protein  with  a  calorie  value  which  is  equal  to  the  calorie  output 
during  starvation,  the  calorie  output  will  increase  by  30  per  cent, 
whereas  with  carbohydrates  it  will  increase  by  only  6  per  cent. 
Evidently,  then,  protein  liberates  much  free  heat  during  its  as- 
similation in  the  animal  body;  it  burns  with  a  hotter  flame  than 
fats  or  carbohydrates,  although  before  it  is  completely  burned  it 
may  not  yield  so  much  energy  as  is  the  case,  for  example,  when 
fats  are  burned.  This  peculiar  property  of  proteins  accounts 
for  their  well-known  heating  qualities.  It  explains  why  protein 
composes  so  large  a  proportion  of  the  diet  of  peoples  living  in  cold 
regions,  and  why  it  is  cut  down  in  the  diet  of  those  who  dwell  near 
the  tropics.  Individuals  maintained  on  a  low  protein  diet  may  suf- 
fer intensely  from  cold. 

"If  we  add  to  the  basal  heat  production  of  1,680  C.  another  168 
C.  (or  10  per  cent)  on  account  of  food,  the  total  1,848  C.  neverthe- 
less falls  far  short  of  that  which  we  know  must  be  liberated  when 
we  calculate  the  available  energy  of  the  diet,  which  we  may  take 
as  2,500  C.  What  becomes  of  the  extra  fuel?  The  answer  is  that 
it  is  used  for  muscular  work.  Thus  it  has  been  found  that  if  the 
observed  person,  instead  of  lying  down  in  the  calorimeter,  is  made 
to  sit  in  a  chair,  the  heat  production  is  raised  by  8  per  cent,  or  if 
he  performs  such  movements  as  would  be  necessary  for  ordinary 
work  (writing  at  a  desk)  it  may  rise  29  per  cent — that  is  to  say, 
to  90  C.  per  hour.  There  is,  however,  practically  no  difference  in 
the  energy  output  of  a  person  lying"  flat  or  lying  in  a  >  semi-re- 
clining position,  as  in  a  steamer  chair.  Allowing  eight  hours  for 
sleep  and  sixteen  hours  for  work,  we  can  account  for  about  2,168 
C.,  the  remaining  300  odd  C.  that  are  required  to  bring  the  total 
to  that  which  we  know,  from  statistical  tables  of  the  diets  of  such 
workers,  to  be  the  actual  daily  expenditure,  being  due  to  the  exer- 
cise of  walking.  If  the  exercise  is  more  strenuous,  still  more  calo- 
ries will  be  expended ;  thus,  to  ascend  a  hill  of  1,650  feet  at  the  rate 


354  BLOOD    AND   URINE    CHEMISTRY 

of  2.7  miles  an  hour  requires  407  extra  calories.  Field  workers 
may  expend,  in  24  hours,  almost  twice  as  many  calories  as  those 
engaged  in  sedentary  occupations. 

"Standard  for  Comparison 

"When  the  energy  output  per  kilo  body  weight  is  determined 
in  animals  of  varying  size,  the  values  are  greater  the  lighter  the 
animal.  This  is  evident  from  the  following  results  obtained  on 
dogs: 

Weight  of  dog  Heat  production  in  calories 

per  kilo  per  day 

(1)  31.2  35.68 

(2)  18.2  46.2 

(3)  9.6  65.16 

(4)  0.5  66.07 

(5)  3.19  88.07 

(Rubncr) 

"When,  on  the  other  hand,  instead  of  body  weight,  the  area  of 
the  surface  of  the  body  is  taken  as  the  basis  of  calculation,  results 
that  are  almost  constant  are  obtained.  Following  are  the  results  in 
the  above  animals  on  this  basis : 

Heat  production  in  calories 

Surface  in  square  cm.  per  square  meter  of  sur- 

face per  day 

(1)  10,750  1036 

(2)  7,662  1097 

(3)  5,286  1183 

(4)  3,724  1153 

(5)  2,423  1212 

(Rubncr) 

"Such  results  have  prompted  observers  to  conclude  that  the  de- 
termining factor  in  the  calorie  output  of  warm-blooded  animals  is 
the  relative  surface  of  the  animal.  This  is  greater  the  smaller  the 
animal,  with  the  consequence  that  heat  is  more  rapidly  lost  to  the 
surrounding  air  from  the  surface,  thus  requiring  more  active  com- 
bustion. Until  quite  recently  it  has  been  generally  believed  that 
such  a  relationship  between  body  surface  and  heat  production  did 
actually  exist,  but,  thanks  to  the  work  of  F.  G.  Benedict1  and  E.  F. 
and  D.  l5uBois,2  it  is  now  known  that  the  calculations  were  based 
upon  incorrect  computations  of  the  body  surface.  In  the  older  re- 
searches the  catenation  was  made  by  using  a  formula  known  as 
Meeh's,  in  which  the  weight  was  multiplied  by  a  certain  factor  (viz., 
12.312  X  ^  weight)  Du  Bois,  however,  has  shown  that  an  average 


'Benedict,  F.  G.:     Am.  Jour.  Physiol.,   1916,  xli,   275,  292. 

2Du    Bois,    E.    F.,   and    collaborators:     Clinical    Chemistry,    Papers    1    to   25,    Arch.    Int. 
Med.,  1915-17,  xvi-xix. 


BASAL   METABOLISM 


355 


error  of  16  per  cent  is  incurred  in  using  this  formula.  For  accurate 
measurement  the  body  was  covered  with  thin  underwear,  which  was 
then  impregnated  with  melted  paraffin  and  reinforced  with  paper 
strips  to  prevent  it  from  changing  in  area  when  removed.  This 
model  of  the  surface  was  afterwards  cut  up  into  flat  pieces  and  pho- 
tographed on  paper  of  uniform  thickness,  the  patterns  being  then 
cut  out  and  weighed.  From  the  results  it  was  easy  to  calculate  the 
actual  surface  area. 

' '  Where  the  height  and  weight  are  known,  a  fairly  accurate  com- 
putation of  the  surface  can  be  secured  by  using  the  following  for- 


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WEIGHT-KILOGRAMS 

Fig.  68.  —  Chart  for  determining  surface  area  of  man   in  square  meters  from  weight  in 
rs 
(Fr 


.        . 

kilograms    (Wt.)    and   height   in   centimeters    (Ht.)    according   to   the   formula:      Area    (Sq. 
Cm.)  =  Wt.  0.425   Xllt.   0.725   X71.84.      (From  Du   Bois  and  Du  Bois,   Arch.  Int.   Med., 


1917,  vol.  17.) 


mulas: 


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;  A  being  the  surface  area  in 


square  centimeters;  H  the  height  in  centimeters;  and  W,  the  weight 
in  kilograms.  Based  on  this  formula,  a  chart  has  been  plotted  from 
which  the  surface  area  may  be  determined  at  a  glance,  (Fig.  68). 
Another  method  recently  employed  by  Benedict  is  based  on  meas- 
urements made  from  photographs  of  the  subject  in  various  poses. 
''By  the  use  of  these  more  accurate  measurements  of  body  sur- 
face, it  is  now  known  that,  although  the  surface-area  law  gives  us 
constant  results  for  the  energy  output  of  different  individuals  of 


356  BLOOD   AND   URINE    CHEMISTRY 

similar  build,  and  offers  us  a  much  more  accurate  basis  for  compar- 
ing those  of  different  laboratory  animals  than  body  weight,  yet  it 
breaks  down  when  applied  to  men  in  widely  differing  states  of  body 
nutrition.  Thus,  in  the  case  of  a  man  who  starved  for  a  month,  the 
calorie  output  per  square  meter  of  surface  decreased  towards  the 
end  of  the  fast  by  28  per  cent.  Obviously,  therefore,  it  would  be 
incorrect  to  draw  conclusions  regarding  possible  changes  in  energy 
output  of  a  series  of  emaciated  or  corpulent  individuals  by  com- 
parison of  their  calorie  output  per  square  meter  of  surface  with 
that  of  normal  individuals. 

"The  determining  factor  of  energy  output  is  undoubtedly  the 
general  condition  of  bodily  nutrition — the  active  mass  of  proto- 
plasm of  the  body  (Benedict).  That  there  is  a  relationship  between 
the  body  surface  and  metabolism  is  undoubted,  but  the  relationship 
is  not  a  causal  one.  At  present,  therefore,  the  only  safe  method 
to  employ  in  comparing  the  metabolism  of  normal  and  diseased  in- 
dividuals is  that  called  by  Benedict  "the  group  method,"  in  which 
the  metabolism  of  groups  of  persons  of  like  height  and  weight  is 
compared,  it  being  assumed  that  such  individuals  have  the  same 
general  growth  relations.  For  the  application  of  this  group  method 
however,  more  extensive  data  will  be  required  than  exist  at  pres- 
ent, and  although  some  of  the  conclusions  drawn  from  results 
computed  on  the  surface-area  basis  may  have  to  be  revised,  it  is 
probable  that  they  are  in  general  correct. 

"Influence  of  Age  and  Sex 

' '  The  energy  output  is  low  in  the  newly  born ;  it  increases  rapidly 
during  the  first  year,  reaching  a  maximum  at  about  three  to  six 
years  of  age,  and  then  rapidly  declining  to  about  twenty,  after 
which  it  declines  much  more  slowly.  The  decline  in  the  earlier 
years  does  not  proceed  steadily,  however,  for  at  the  period  just 
preceding  the  onset  of  puberty  a  decided  increase  becomes  evident, 
indicating  that  at  this  period  the  metabolism  of  the  growing  organ- 
ism is  being  stimulated.  Females  have  a  lower  energy  output  than 
males,  and  the  stimulating  influence  of  puberty-  is  less  marked  in 
them. 

"In  round  numbers,  40  C.  per  square  meter  of  surface  per  hour 
is  the  energy  output  of  normal  men,  a  15  per  cent  deviation  being 
considered  as  decidedly  abnormal.  The  average  metabolism  of 


BASAL    METABOLISM  357 

fat  and  thin  subjects  is  the  same,  but  that  of  women  is  6.8  per  cent 
lower  than  that  of  men.  The  basal  metabolism  of  a  group  of  men 
and  women  between  the  ages  of  forty  and  fifty  was  4.3  per  cent 
below  the  average  for  the  larger  group  between  the  ages  of  twenty 
and  fifty;  and  that  of  a  group  between  fifty  and  sixty  years  was 
11.3  per  cent  lower. 

"Influence  of  Diseases 

"The  measurements  have  been  made  by  the  direct  method  which 
has  just  been  described,  but  since  a  much  simpler  indirect  method 
yields  comparable  results,  it  is  being  adopted  for  clinical  pur- 
poses. These  results  were  obtained  by  making  parallel  deter- 
minations of  energy  output  by  both  methods,  in  disease  as  well 
as  in  health.  Some  of  the  observations  that  have  been  made  on 
the  energy  output  in  various  diseases  are  as  follows:  In  very  se- 
vere cases  of  exophthalmic  goiter,  heat  production  may  be  increased 
by  75  per  cent  over  the  normal;  in  severe  cases,  by  50  per  cent. 
The  warmth  of  the  skin  and  the  sweating,  which  are  prominent 
symptoms  of  this  disease,  are  therefore  accounted  for  by  the  in- 
creased elimination  of  heat,  and  it  is  considered  possible  that  the 
other  symptoms  would  be  produced  in  any  normal  individual  were 
his  metabolism  maintained  for  months  or  years  at  the  high  level 
which  it  occupies  in  goiter.  In  the  opposite  condition  of  myxedema, 
the  energy  output  is  markedly  reduced,  but  rises  slowly  during 
treatment  with  thyroid  extract,  or  much  more  rapidly  with  the 
very  active  thyroid  hormone  recently  isolated  by  Kendall.  In  dia- 
betes it  has  often  been  thought  that  the  rapid  emaciation  and  loss 
of  strength  were  dependent  upon  an  excited  state  of  metabolism, 
or  a  useless  burning  up  of  the  energy  material.  The  most  recent 
work,  however,  clearly  shows  that  this  is  not  the  case,  the  basal 
metabolism  as  calculated  per  unit  of  body  surface  being  within 
the  limits  indicated  above.  During  the  starvation  treatment  the 
energy  output  may  be  much  below  the  normal.  In  uncompensated 
cases  of  cardiorenal  disease,  there  is  increased  energy  output.  In 
pernicious  anemia  the  metabolism  is  normal,  although  in  severe 
cases  there  may  be  an  increased  demand  for  oxygen. 

"Even  at  the  risk  of  repetition,  it  is  important  to  point  out  that 
in  all  these  diseases  the  energy  output  is  the  same  whether  measured 
directly  or  by  the  indirect  method  about  to  be  described. 


358  BLOOD   AND    URINE    CHEMISTRY 

"THE  MATERIAL  BALANCE  OF  THE  BODY 

"We  must  distinguish  between  the  balances  of  the  organic  and 
the  inorganic  foodstuffs.  From  a  study  of  the  former  we  shall  gain 
information  regarding  the  sources  of  the  energy  production  whose 
behavior  under  various  conditions  we  have  just  studied.  From  a 
study  of  the  inorganic  balance,  although  we  shall  learn  nothing 
regarding  energy  exchange — for  such  substances  can  yield  no  en- 
ergy— we  shall  become  acquainted  with  several  facts  of  extreme 
importance  in  the  maintenance  of  nutrition  and  growth. 

"To  draw  up  a  balance  sheet  of  organic  intake  and  output  re- 
quires an  accurate  chemical  analysis  of  the  food  and  of  the  excreta 
(urine  and  expired  air). 

"Methods  for  Measuring1  Output 

"The  principle  by  which  the  output  is  measured  will  be  under- 
stood by  referring  to  Fig.  69,  from  which  it  will  be  seen  that  the 
calorimeter  is  connected  with  a  closed  system  of  tubes  provided 
with  an  air-tight  rotary  blower  or  pump  to  maintain  a  constant  cur- 
rent of  air,  as  indicated  by  the  arrows.  Following  the  air  stream 
as  it  leaves  the  chamber,  we  note  a  side  tube  connecting  with  a 
meter  to  indicate  changes  in  volume  of  the  air  in  the  system.  Be- 
yond this  and  the  pump  is  a  specially  constructed  bottle  containing 
concentrated  H2S04,  then  one  containing  soda  lime,  and  lastly  an- 
other H2S04  bottle.  The  first  H2S04  bottle  absorbs  all  the  water 
vapor  contained  in  the  air  coming  from  the  chamber ;  the  soda  lime 
bottle  absorbs  the  Co2,  and  the  second  H2S04  bottle  absorbs  water 
that  is  produced  in  the  chemical  reaction  involved  in  the  absorption 
of  the  C02  by  the  soda  lime  (2NaOH  +  C02  =  H,0  +  Na2C03) .  By 
weighing  these  absorption  bottles  before  and  after  an  animal  has 
been  for  some  time  in  the  chamber,  the  weight  of  H20  and  of  C02 
given  out  can  be  determined.  Another  side  tube  leads  to  an  oxygen 
cylinder,  the  valve  of  which  is  manipulated  so  as  to  cause  oxygen 
to  be  discharged  into  the  system  at  such  a  rate  as  to  compensate 
exactly  for  that  used  up  by  the  animal,  as  indicated  by  the  behavior 
of  the  meter.  The  amount  of  oxygen  required  is  determined  either 
by  weighing  the  oxygen  cylinder  before  and  after  the  observation 
or  by  measuring  the  volume  of  oxygen  used  by  passing  it  through 
a  carefully  calibrated  and  very  sensitive  water  meter  inserted  on 


BASAL    METABOLISM 


359 


the  side  tube  that  connects  the  0,  cylinder  with  the  main  tubing 
of  the  system.  Since  muscular  activity  causes  pronounced  changes 
in  the  rate  of  metabolism,  means  are  usually  taken  to  secure  graphic 
records  of  any  movements  made  during  the  observation. 

"The  growing  importance  in  clinical  investigations  of  measure- 
ments of  the  respiratory  exchange  and  the  necessity  for  having 
methods  that  are  as  simple  as  is  consistent  with  accuracy,  have  led 
to  the  introduction  of  several  other  forms  of  apparatus,  of  which 
those  of  F.  G.  Benedict  and  of  Tissot*  are  the  most  important.  In 


T  ,T 

I       Y//////////////////////////ffffiffdffif/$lffiffiffifa    I 

)wmwmmmmwmmffl\ 

-*-    water  to  absorb   heo.t  _  !±7~ 


Fig.  69. — Diagram  of  Atwater-Benedict  respiration  calorimeter.  As  the  animal  uses  up 
the  Oo,  the  total  volume  of  air  shrinks.  This  shrinkage  is  indicated  by  the  meter,  and 
a  corresponding  amount  of  O2  is  delivered  from  the  O2-cylinder.  The  increase  in  weight 
of  bottles  II  and  III  gives  the  CO2;  that  of  I,  the  water  vapor. 

the  former  a  tightly  fitting  mask,  applied  over  the  nose  and  mouth  is 
connected,  by  a  short  T-piece,  with  the  same  tubing  as  that  used  in 
the  respiration  calorimeter.  The  patient  thus  breathes  jn  and  out 
of  the  air  stream  that  is  passing  along  the  tubing  without  any  of 
the  obstruction  experienced  when  the  breathing  has  to  be  performed 
through  valves,  as  in  the  older  (Zuntz)  forms  of  portable  respiratory 
apparatus.  It  is  particularly  for  studies  on  man  that  this  ap- 

*The  Tissot  method  will  be  found  described  in  full  elsewhere  (page  369). 
[The    Benedict    respiratory    apparatus    made    by    Sanborn    Company,    Boston,    is    very 
satisfactory.] 


360  BLOOD   AND   URINE    CHEMISTRY 

paratus  has  been  devised.  The  Tissot  and  Douglas  methods  are 
shown  in  Figs.  72  and  73. 

"To  complete  the  investigation,  it  is  necessary  that  the  urine  and 
feces  be  collected  and  the  nitrogen  excretion  measured.  When  the 
respiratory  excreta  are  measured  over  a  considerable  period  of 
time,  as  in  the  large  calorimeter,  the  urine  is  collected  for  the  same 
period,  but  when  shorter  respiratory  measurements  are  made,  the 
urine  of  the  twenty-four  hours  is  usually  taken. 

"Principles  Involved  in  Calculating  the  Results. — Provided 
with  the  analyses  furnished  by  the  above  methods,  we  proceed  to 
ascertain  the  total  amounts  of  nitrogen  and  carbon  excreted  and  to 
calculate  from  the  known  composition  of  protein  how  much  pro- 
tein must  have  undergone  metabolism.  We  then  compute  how 
much  carbon  this  quantity  of  protein  would  account  for,  and  we 
deduct  this  from  the  total  carbon  excretion.  The  remainder  of 
carbon  must  have  come  from  the  metabolism  of  fats  and  carbohy- 
drates, and  although  we  cannot  tell  exactly  which,  yet  we  can  ar- 
rive at  a  close  approximation  by  observing  the  respiratory  quotient 
(R.  Q.),  which  is  the  ratio  of  the  volume  of  carbon  dioxide  exhaled 

CO 
to  that  of  oxygen  retained  by  the  body  in  a  given  time,  i.  e.,        2* 

By  observing  this  quotient,  therefore,  we  can  approximately  deter- 
mine the  source  from  which  the  nonprotein  carbon-excretion  is 
derived. 

"Having  in  the  above  manner  computed  how  much  of  each  of  the 
proximate  principles  has  undergone  metabolism,  we  next  proceed 
to  compare  intake  and  output  with  a  view  to  finding  whether  there 
is  an  equilibrium  between  the  two,  or  whether  retention  or  loss  is 
occurring. 

"It  may  serve  to  make  clear  the  methods  by  which  these  calcu- 
lations are  made  to  study  the  following  example: 

"Example  of  a  Metabolism  Investigation.- — It  is  desired  to  know  whether  a 
diet  containing  125  grams  protein,  50  grams  fat,  and  500  grams  carbohydrate 
is  sufficient  for  a  man  doing  a  moderate  amount  of  work. 

INTAKE 

Carbon  Nitrogen            Calorics 

Protein,                               62  gm.  20  gm.                 512.5 

Carbohydrate,                  200  2050.0 

Fat,                                      38  465.0 


Total,  300  gm.  20  gm.  3027.5 


BASAL    METABOLISM  361 


OUTPUT 

Carbon  Nitrogen 

In    urine,  11  gra.   (16.5x0.67)          16.5  gm. 

In  feces,  5  1.0 

In  the  breath,  254 


Total,  270  gm.  17.5  gm. 

"Retained  in  Body. — 30  gm.  carbon  and  2.5  gm.  nitrogen.  This  amount  of 
nitrogen  represents  2.5  x  6.25  — 15.6  gm.  protein  or  75  gm.  muscle.  Now,  this 
amount  of  protein  will  account  for  8.25  gm.  carbon;  so  that  30-8.25  —  21.75 
gm.  carbon  represents  21.75  x  1.3  —  28.3  gm.  fat.  On  this  diet,  therefore,  the 
subject  retains  in  his  tissues  15.6  gm.  protein  and  28.3  gm.  fat  per  diem. 

' '  Furnished  with  these  data  we  may  now  proceed  to  compute  how 
much  energy  must  have  been  liberated  in  the  body. 

"To  express  the  above  result  in  terms  of  energy  liberated,  we 
know  that  3027.5  C.  were  supplied  and  that  all  these  have  been  used 
except  15.6  x  4.1  =  64  retained  as  protein,  and  28.3  x  9.3  =  263.2 
retained  as  fat ;  or  in  toto  327.2  C.  We  find,  therefore,  that  3027.5 
—  327.2  =  2,700  C.  have  been  required. 

"This  is  called  the  method  of  indirect  calorimetry,  and  it  has 
been  clearly  established  by  numerous  observations  that  the  results 
agree  exactly  with  those  secured  by  the  method  of  direct  calorime- 
iry  described  above.  For  most  purposes  the  indirect  method  is 
quite  satisfactory,  and  it  is  especially  valuable  in  cases  in  which 
there  are  considerable  and  sudden  changes  in  body  temperature. 
That  the  results  by  the  two  methods  should  agree  shows  clearly 
that  the  law  of  the  conservation  of  energy  must  apply  in  the  animal 
body,  for  it  is  evident  that  if  any  energy  were  derived  from  outside 
the  body  other  than  that  taken  with  the  food,  the  results  by  the 
direct  method  would  be  higher  than  those  by  the  indirect. 

"THE  CARBON  BALANCE 

"Before  proceeding  to  discuss  the  special  metabolism  of  pro- 
teins, fats  and  carbohydrates,  it  will  be  advantageous  to  consider 
briefly  some  general  facts  concerning  the  excretion  of  carbon  diox- 
ide and  the  intake  of  oxygen.  In  the  first  place,  it  is  important  to 
note  that  the  extent  of  the  combustion  process  in  the  animal  body 
is  proportional  to  the  amount  of  oxygen  absorbed  and  of  carbon 
dioxide  produced,  whereas  the  nature  of  the  combustion  is  indi- 
cated by  the  ratio  existing  between  the  amounts  of  carbon  dioxide 
expired  and  of  oxygen  retained  in  the  body.  An  investigation  of 
the  carbon  balance,  in  other  words,  is  partly  quantitative  and 


362  BLOOD   AND   URINE    CHEMISTRY 

partly  qualitative — quantitative  in  the  sense  that  it  indicates  how 
intensely  the  body  furnaces  are  burning,  and  qualitative  in  the 
sense  that  it  tells  us  what  sort  of  material  is  being  burned  at  the 
time. 

"THE  RESPIRATORY  QUOTIENT 

"Influence  of  Diet. — The  respiratory  quotient  is  determined  by 
comparison  of  the  volume  of  carbon  dioxide  expired  with  the  vol- 
ume of  oxygen  meanwhile  retained  in  the  body  or,  as  a  formula, 

Vol.  C02  expired 
Vol    02  retained 

For  the  sake  of  brevity  the  respiratory  quotient  is  often  written 
B.  Q.  That  it  serves  as  an  indicator  of  the  kind  of  combustion 
occurring  will  be  evident  from  the  following  equations: 

1.  Carbohydrate:  C^.,0^  +  6O2  =  6CO2  +  6HnO 

(Dextrose.) 

CO2         6 

/.  R.Q.= =  —  =  1. 

(X          6 

2.  Fat:  C3H5(C]SH33O,)3  +  8002  =  57CCX  +  52H2O 

(Olein.) 

CO,       57 
.'.  R.Q.= -  =  —  0.71 

O2         80 

3.  Protein:  C72H112NI&Ot!S+  77O,  =  63COa+  3SH2O  +  9CO(NH2).  +  SO3 

[Empirical  formula  for 
albumin   (Lieberkuhn) .] 
CO2       63 

.'.  R.Q.= =  —  =  0.82 

O,         77 
4.  Conversion  of  fat  into  carbohydrate: 

2C,H,(C18HMO,),  +  6402  =  16C,HWO6  4  18CO,  +  8H2O 
(Olein.) 

CO2       18 

.'.  E.Q.  = =  —  =  0.281 

02         64 
5.  Conversion  of  carbohydrate  into  a  mixed  fat: 

13C6H1206  =  CMHI04Ofl  +  2300,  +  26H2O. 
(Oleostearopalmitin.) 

"Taking  carbohydrates  first,  the  general  formula  may  be  written 
CII20,  from  which  it  is  plain  that,  to  oxidize  the  molecule,  oxygen 
will  be  required  to  combine  with  the  carbon  alone,  according  to 
the  equation,  CH20  +  O=C02  +  H20.  In  other  words,  the  volume 
of  carbon  dioxide  produced  by  the  combustion  will  be  exactly  equal 


BASAL    METABOLISM  363 

to  the  volume  of  oxygen  used  in  this  process,  in  obedience  to  the 
well-known  gas  law  that  equimolecular  quantities  of  different  gases 
occupy  the  same  volume.  The  respiratory  quotient  is  therefore 
unity  (Equation  1).  With  fats  and  proteins,  however,  the  general 
formula  must  be  written  CH2  +  0,  indicating  therefore  that  for  its 
complete  oxidation  the  molecule  must  be  supplied  with  oxygen  in 
sufficient  amount  to  combine  not  only  with  all  of  the  carbon,  but 
also  with  some  of  the  hydrogen,  forming  water ;  so  that  the  volume 
of  C02  produced  will  be  less  than  the  volume  of  oxygen  retained, 
and  the  respiratory  quotient  will  be  less  than  unity.  As  a  matter 
of  fact,  as  the  above  equations  show  (2  and  3),  the  respiratory  quo- 
tient for  fats  and  proteins  lies  somewhere  between  0.7  and  0.8,  being 
usually  nearer  0.7  in  the  case  of  fats,  and  nearer  to  0.8,  in  the  case 
of  proteins. 

"That  the  conditions  hypothecated  in  the  equations  exist  in  the 
animal  body  during  the  combustion  of  the  foodstuffs  can  easily  be 
shown  by  observing  the  respiratory  quotient  of  animals  on  different 
diets.  An  herbivorous  animal,  such  as  a  rabbit,  when  it  is  well  fed 
gives  invariably  a  respiratory  quotient  of  about  1,  whereas  a 
strictly  carnivorous  animal,  such  as  the  cat,  gives  a  respiratory 
quotient  of  about  0.7.  Even  more  striking  perhaps  is  the  compari- 
son of  the  respiratory  quotients  in  an  herbivorous  animal  while  it 
is  well  fed  and  after  it  has  been  starved  for  a  day  or  two.  In  the 
latter  case  the  respiratory  quotient  will  fall  to  a  low  level  because, 
by  starvation,  the  animal  has  been  compelled  to  change  its  com- 
bustion material  from  the  carbohydrate  of  its  food  to  the  protein 
and  fat  of  its  own  tissues. 

"As  already  explained  (page  360,)  it  is  from  the  respiratory  quo- 
tient that  we  are  enabled  to  tell  what  proportions  of  fat  and  carbo- 
hydrate, respectively,  are  undergoing  metabolism.  A  useful  table 
showing  the  percentage  of  calories  produced  by  each  of  these  food- 
stuffs, after  allowing  for  protein  is  given  by  Graham  Lusk  (see  page 
381). 

"Influence  of  Metabolism. — Apart  from  diet,  the  respiratory 
quotient  may  often  be  altered  by  changes  in  the  metabolic  habits 
of  the  animal.  These  are  most  conspicuously  exhibited  in  the  case 
of  hibernating  animals.  In  the  autumn  months,  when  the  animal 
is  eating  voraciously  of  all  kinds  of  carbohydrate  food  and  deposit- 
ing large  quantities  of  adipose  tissue  in  his  body,  the  respiratory 


364  BLOOD   AND   URINE    CHEMISTRY 

quotient  may  be  considerably  greater  than  unity,  indicating  there- 
fore either  that  relatively  more  carbon  dioxide  is  being  discharged 
or  less  oxygen  retained.  As  a  matter  of  fact,  it  can  easily  be  shown 
that  it  is  the  former  of  the  causes  that  is  responsible  for  the  higher 
quotient,  the  explanation  for  the  increased  production  of  C02  be- 
ing that,  as  the  carbohydrate  changes  into  fat,  the  relative  excess 
of  carbon  in  the  former  is  got  rid  of  as  C02,  as  indicated  in  Equa- 
tion 5.  On  the  other  hand,  if  the  animal  is  examined  while  in  his 
winter  sleep,  it  will  be  found  that  the  respiratory  quotient  is  now 
extremely  lowr,  often  not  more  than  0.3  to  0.4,  which  may  be  inter- 
preted as  indicating  either  an  excessive  absorption  of  oxygen  or  a 
markedly  decreased  excretion  of  carbon  dioxide.  As  a  matter  of 
fact,  there  is  a  great  diminution  in  both  the  excretion  of  carbon 
dioxide  and  the  intake  of  02,  because  the  wrhole  metabolic  activity 
of  the  animal  is  extremely  depressed,  but  this  diminution  affects 
the  oxygen  to  a  much  less  degree,  indicating  therefore  a  relative 
increase  in  the  oxygen  retention.  The  explanation  is  that  the  oxy- 
gen is  being  used  in  the  chemical  process  involved  in  the  conversion 
of  the  fat  back  into  carbohydrate. 

"Whatever  may  be  the  relationship  between  fat  and  carbohy- 
drate in  the  nonhibernating  animal,  there  is  no  doubt  that  during 
hibernation,  before  the  fat  stores  are  burned,  fat  is  converted  into 
something  closely  related  to  carbohydrates,  the  equation  for  the 
process  being  represented  as  given  above  (No.  4). 

''In  man  and  the  higher  mammalia,  the  only  condition  apart 
from  diet  which  can  affect  the  nature  of  the  combustion  process  is 
disease;  thus  in  total  diabetes  the  organism  loses  the  power  of  burn- 
ing carbohydrate,  so  that  whatever  the  diet  may  be,  the  respiratory 
quotient  is  very  low,  never  higher  than  that  representing  combus- 
tion of  fat  and  protein.  It  has  been  claimed  by  certain  investiga- 
tors that  in  diabetes  the  respiratory  quotient  may  fall  considerably 
below  0.7,  indicating,  as  in  hibernating  animals,  that  fat  is  being 
converted  into  carbohydrate.  The  most  recent  and  carefully  con- 
trolled observations,  however,  deny  this  claim,  and  for  the  present  we 
must  assume  that  in  the  body  of  man  fat  is  not  converted  into 
carbohydrate.  In  numerous  other  diseases  investigated  by  Du 
Bois  and  others  no  qualitative  change  in  the  combustion  processes 
in  man  has  been  brought  to  light. 


BASAL    METABOLISM  365 

"THE  MAGNITUDE  OF  THE  RESPIRATORY  EXCHANGE 

' '  It  is  evident  that  the  amount  of  carbon  dioxide  expired  and  of 
oxygen  retained  will  be  proportional  to  the  energy  liberation  in 
the  animal  body.  Even  at  the  risk  of  repetition  it  should  be  noted 
that  the  energy  exchange  can  be  very  accurately  calculated  from 


ANIMAL 

WEIGHT 
GM. 

OXYGEN   AB- 
SORBED PER  KILO 
AND    HOUR 
GM. 

CARBON     DIOXIDE 
DISCHARGED 
PER   KILO 
AND   HOUR 
GM. 

VOL.  C02 
VOL.  02 

TEMPERA- 
TURE OF 
AIR 

Insecta 

Field  c-ricket 

0.25 



2.305 





Amphibia 

Edible  frog 

0.063 

0.060 

0.69 

15°-19° 

(44.2  c.c.) 

(30.76  c.c.) 

0.105 

0.1134                   0.78 

— 

(73.4  c.c.) 

(57.7  c.c.) 

Avea 

Common  lien 

1280 

1.05S 

1.327 

0.91 

19° 

(740  c.c.) 

(675  c.c.) 

Pigeon 

232-380 



3.236 

— 

Sparrow 

22 

9.595 

10.492                   0.79 

18° 

(6710  c.c.) 

(5334.5  c.c.)| 

Mammalia 

Ox 

'638,000 



0.389-0.485 

— 

660,000 

Sheep 

66,000 

0.490 

0.671 

0.99 

16° 

(343  c.c.) 

(341  c.c.) 

Dog 

6213 

1.303 

1.325 

0.74 

15° 

(911  c.c.) 

(674  c.c.) 

Cat 

2464 

1.356 

1.397 

0.75 

-3.2° 

3047 

(947  c.c.) 

(710  c.c.) 

3047 

0.645 

0.766                     0.86 

29.6° 

(450  c.c.) 

(389  c.c.) 

Rabbit 

1433 

1.012 

1.354 

0.97 

18°-20° 

Guinea  pig 

444.9 

1.478 

1.758 

0.86 

22° 

Eat  (white) 

80.5 



3.518 

— 

7° 

(1789c.e.) 

Mouse      '  ' 

25 



8.4 

— 

17° 

Man 

66.700 

0.292 

0.327 

— 

— 

(Modified  from  Pembrey.)!? 

the  result  of  the  material  balance  sheet — indirect  caloriraetry,  as 
it  is  called  (page  378).  On  account  of  the  comparative  simplicity 
of  measuring  the  carbon  dioxide  output  and  oxygen  intake,  it  is 
natural  that  many  of  the  observations  that  have  been  made  on  en- 
ergy production  in  the  animal  body  depend  on  the  use  of  this 
method,  justification  for  which  is  found  in  the  complete  agreement 


366  BLOOD   AND   TIRTNE    CHEMISTRY 

between  the  results  of  direct  and  indirect  calorimetry  in  a  great 
variety  of  diseases  and  conditions  in  man  (Du  Bois).* 

"In  the  first  place,  it  is  interesting  to  compare  the  respiratory 
exchanges  of  different  animals  computed  per  kilo  body  weight. 
This  is  shown  in  the  table  on  page  365. 

"Several  factors  operate  to  explain  these  differences,  and  of 
these  the  following  are  of  importance : 

"1.  The  Body  Temperature. — Increase  in  body  temperature  en- 
tails increased  combustion.  This  explains  why  the  metabolism  of 
a  bird  is  greater  than  that  of  a  mammal  of  the  same  size,  for,  as  is 
well  known,  the  temperature  of  a  bird  is  two  or  three  degrees  centi- 
grade above  that  of  other  animals.  Rise  in  body  temperature  also 
explains,  in  part  at  least,  the  increased  metabolism  observed  in 
fever. 

"2.  The  Temperature  of  the  Environment. — In  considering  this 
we  must  distinguish  between  the  effect  produced  on  warm-blooded 
and  on  cold-blooded  animals.  Since  the  body  temperature  of  a  cold- 
blooded animal  is  only  one  or  two  degrees  Centigrade  above  that  of 
its  environment,  it  follows  that  the  metabolic  activity  will  be  di- 
rectly proportional  to  the  temperature  of  the  latter.  In  a  warm- 
blooded animal,  on  the  other  hand,  the  body  temperature  remains 
constant  whatever  changes  may  occur  in  that  of  the  environment, 
this  constancy  of  body  temperature  being  dependent  on  the  fact 
that  the  intensity  of  the  combustion  processes  is  inversely  propor- 
tional to  the  cooling  effect  of  the  atmosphere.  Thus,  suppose  the 
external  temperature  should  fall,  then  the  loss  of  heat  from  the 
body  will  tend  to  become  greater,  and  to  maintain  the  body  tem- 
perature at  a  constant  level,  the  body  furnaces  must  burn  more 
briskly,  with  the  result  that  an  increased  excretion  of  carbon  diox- 
ide and  intake  of  oxygen  will  occur. 

"This  influence  of  the  surrounding  atmosphere  on  the  metabolic 
activity  of  warm-blooded  animals  has,  as  already  pointed  out,  been 
used  by  several  investigators  to  explain  the  greater  combustion  per 
kilo  body  weight  of  small  as  compared  with  large  animals.  The  ar- 
gument is  that,  since  the  surface  of  small  animals  relatively  to 
their  mass  is  much  greater  than  in  large  animals,  the  cooling  of 

*For  the  convenience  of  those  who  may  desire  to  know  more  anotit  the  methods  of 
analysis  that  are  suitable  in  the  clinic,  a  chapter  on  the  subject  will  be  found  beginning 
on  page  554.  [Bottom  of  page  368  in  this  book.] 


BASAL    METABOLISM  367 

r 

the  small  animals  will  be  proportionately  greater.  The  relation- 
ship between  surface  and  mass  is  shown  by  taking  two  cubes  and 
putting  them  together ;  the  mass  of  the  two  cubes  is  equal  to  double 
that  of  either  cube,  whereas  the  surface  is  less  than  double,  since 
two  aspects  of  the  cubes  have  been  brought  together.  To  prove 
the  contention,  the  respiratory  exchange  has  been  computed  per 
square  meter  of  surface  instead  of  per  kilo  body  weight,  with  the 
result  that  a  very  close  correspondence  in  the  metabolism  of  dif- 
ferent animals  has  been  observed ;  but  this  question  has  already 
been  discussed,  and  we  now  know  that  the  law  of  cooling  cannot 
be  the  only  one  that  determines  extent  of  the  respiratory  exchange. 
''3.  Muscular  Exercise. — This  has  a  most  important  influence 
on  the  exchange  and  it  is  particularly  in  connection  with  it  that 
studies  in  carbon-dioxide  output  and  oxygen  intake  have  been  of 
great  practical  value,  particularly  when  the  investigations  are  un- 
dertaken on  men  doing  ordinary  types  of  muscular  exercise,  such 
as  walking  or  climbing.  It  is  true  that  the  influence  of  muscular 
exercise  on  the  energy  metabolism  may  also  be  studied  by  having 
a  person  in  the  calorimeter  do  exercises  on  an  ergometer,  but  the 
results  thus  obtained  are  in  many  ways  not  nearly  so  valuable  as 
those  which  can  be  secured  by  observing  the  respiratory  exchange 
of  persons  doing  ordinary  types  of  muscular  exercise  in  the  open. 
The  following  table  of  observations  on  horses  is  of  interest  in  this 
connection : 


CONDITION 

AIR   EXPIRED 
IN    LITERS 
PER  MINUTE 

CARBON  DIOXIDE 
DISCHARGED   IN 
LITERS  PER 
MINUTE 

OXYGEN    ABSORBED                  co 
IN  LITERS  PER                      —  - 
MINUTE 

Rest 
Walk 
Trot 

44 

177 
333 

1.478 

4,342 
7.516 

1.601 
4.766 

8.093 

0.92 
0.90 
0.93 

"It  will  be  observed  that  the  metabolism  increases  extraordi- 
narily for  even  a  moderate  degree  of  work,  but  that  at  the  same  time 
the  respiratory  quotient  remains  constant.  From  observations  on 
the  respiratory  exchange  of  working  men  and  animals,  extremely 
important  facts  concerning  the  efficiency  of  musclar  work  have  been 
secured.  The  form  of  respiratory  apparatus  (Zuntz  or  Douglas)  em- 
ployed for  this  purpose  must  be  capable  of  being  strapped  on  the 
man 's  back  without  causing  any  embarrassment  to  his  bodily  move- 


368  BLOOD   AND   URINE    CHEMISTRY 

ments.  By  a  comparison  of  the  respiratory  exchange  with  the 
amount  of  work  done,  the  efficiency  of  the  work  can  readily  be  de- 
termined. It  has  been  found,  for  example,  that  the  efficiency  is 
much  greater  after  the  man  or  animal  has  got  into  the  swing 
of  the  work,  his  energy  expenditure  per  unit  of  work  being 
much  greater  during  the  first  half  hour's  work  in  the  morn- 
ing than  it  is  later  on.  This  indicates  that  after  a  little  prac- 
tice the  muscles  can  execute  a  given  movement  and  perform 
a  given  amount  of  work  much  more  smoothly  than  when  they 
are  not  in  training.  Another  interesting  outcome  of  the  inves- 
tigations has  been  to  show  that  work  done  under  abnormal  con- 
ditions that  tend  to  produce  any  kind  of  muscular  strain  is 
done  inefficiently.  It  has  been  found  in  marching  soldiers, 
for  example,  that  the  slightest  abrasion  of  the  foot  greatly  in- 
creases the  energy  expenditure,  for  the  man,  in  trying  to  avoid 
the  pain  produced  by  the  abrasion,  brings  into  operation  muscular 
groups  that  are  really  not  required  for  the  efficient  performance  of 
the  movement,  but  are  used  instead  to  avoid  pressure  on  the 
sore.  Fatigue  also  causes  inefficient  performance  of  work;  that 
is  to  say,  the  fatigued  person,  on  attempting  the  same  amount  of 
work  as  he  performed  before  becoming  fatigued,  will  do  so  at  a 
much  greater  expenditure  of  energy. 

' '  There  is  a  diurnal  variation  in  the  respiratory  exchange,  which 
is  in  general  parallel  with  the  body  temperature;  it  rises  during 
the  day,  the  time  of  activity  and  work,  and  falls  during  the  night, 
the  time  of  rest  and  sleep.  Food  also  affects  respiratory  exchange, 
but  it  will  be  unnecessary  to  go  into  this  further  after  what  has 
been  said  on  page  362." 

The  following  matter  is  taken  from  the  Chapter  on  "A  Clinical 
Method  for  Determining  the  Respiratory  Exchange  in  Man,  "*  by 
Dr.  R.  G.  Pearce,  in  Dr.  Macleod's  Physiology  and  Biochemistry 
in  Modern  Medicine : 

"Principle. — Since  the  determination  of  the  respiratory  ex- 
change in  man  is  of  some  importance  in  the  study  of  certain  dis- 
eases of  the  respiration,  circulation  and  metabolism,  and  also  be- 
cause directions  for  carrying  out  the  necessary  procedures  are  not 
generally  available,  we  have  thought  it  might  be  of  assistance  to  in- 


*This  chapter  is  added   for  the   convenience    of  workers   in   this  subject. 


BASAL    METABOLISM 


369 


elude  here  brief  directions  for  the  Tissot  and  the  Douglas  methods. 
These  methods  have  been  found  to  compare  favorably  in  accuracy 
with  others  in  use  at  present,*  and  because  of  their  adaptability  and 
simplicity  they  are  especially  suited  for  clinical  work. 

"By  these  methods  the  energy  metabolism  of  the  body  is  calcu- 


Fig.    70.— A,    Nose   clip;    B,    Face   mask;    C,    Mouth    piece. 

- 

lated  from  oxygen  consumption  or  carbon  dioxide  excretion  per 
minute  (indirect  calorimetry)  (page  362),  the  figures  for  which  are 
determined  from  the  volume  and  percentile  gaseous  composition 
of  the  expired  air. 


*Carpenter:     Carnegie   Institution   of   Washington   Reports,   No.   216,    1915. 


370 


BLOOD    AND    URINE    CHEMISTRY 


' '  The  subject  breathes  through  valves  which  automatically  parti- 
tion the  inspired  and  expired  air.  The  expirations  from  a  number 
of  respirations  are  collected  in  a  spirometer  or  bag,  and  the  volume 
of  the  respirations  per  minute  is  determined.  The  gaseous  com- 
position of  the  expired  air  is  determined  by  gas  analysis,  and  the 
oxygen  consumption  and  energy  output  of  the  body  are  calculated 
from  the  data  obtained. 

"Description  and  Use  of  Parts  of  the  Apparatus:  1.  THE 
MOUTHPIECE  AND  VALVE. — The  mouthpiece  is  made  of  soft  pure 
gum  rubber,  and  consists  of  an  elliptical  rubber  flange  having  a 
hole  in  the  center  2  cm.  in  diameter,  to  which  on  one  side  a  short 
rubber  tube  is  attached.  On  the  opposite  side  of  the  hole,  at  right 
angles  to  the  rubber  flange,  are  attached  two  rubber  lugs.  The 
rubber  flange  is  placed  between  the  lips,  and  the  lugs  are  held  by 


Fig.  71. — Diagram  of  respiratory  valves. 

the  teeth.  The  rubber  tube  of  the  mouthpiece  is  connected  to  the 
tube  carrying  the  valves.  The  nose  must  be  tightly  closed  if  mouth 
breathing  is  used.  This  is  accomplished  by  a  nose  clip,  which  con- 
sists of  a  V-shaped  metal  spring,  the  ends  of  which  are  provided 
with  felt  pads.  A  toothed  ratchet  is  attached  to  the  ends  of  the 
spring,  and  serves  to  hold  the  spring  tightly  clamped  on  the  nos- 
trils in  the  proper  position  (see  Fig.  70). 

"Some  individuals  experience  great  distress  when  made  to 
breathe  through  the  mouth.  For  these  it  is  best  to  use  a  face  mask. 
Unfortunately  at  the  present  time  no  mask  is  entirely  satisfactory. 
Perhaps  the  best  is  one  sold  by  Siebe,  Gorman  &  Co.,*  which  is  pic- 
tured in  the  cut.  After  being  placed  in  position  the  face  mask 
should  be  tested  for  leaks,  which  can  be  done  by  putting  soap 
around  the  edges. 


*This   mask    has   been    used    extensively    by    Ca 
fl.    N.    Kliner,    1140   Monadnock    Bldg.,    Chicago. 


The    agent    in    this   country    is 


BASAL    METABOLISM  371 

"2.  THE  VALVES. — The  valves  of  Tissot  are  probably  the  best  for 
the  purpose,  but  they  are  expensive  and  difficult  to  obtain.  We 
have  made  perfectly  satisfactory  valves  from  the  prepared  casings 
used  in  the  manufacture  of  bologna  sausage.  These  can  be  obtained 
preserved  in  salt,  and  they  will  keep  indefinitely  on  ice.  When 
needed  a  short  piece  is  taken,  washed  free  from  salt  by  allowing 
water  from  the  tap  to  run  through  it,  and  softened  in  a  weak  glyc- 
erine solution.  The  gut  becomes  very  soft  and  pliable,  and  does  not 
dry  quickly.  A  piece  of  the  casing  about  10  cm.  long  is  threaded 
through  a  glass  tube  of  about  15  mm.  bore  and  4  to  6  cm.  long. 
One  end  of  the  casing  is  brought  around  the  outside  of  the  tubing 
and  secured  by  means  of  a  thread.  The  lower  end  of  the  membrane 
is  pinched  off  and  the  casing  is  then  cut  a  little  more  than  half 
way  across  its  middle,  so  that  the  opening  will  lie  just  within  the 
free  end  of  the  tube  when  the  casing  is  drawn  back  through  it. 
The  loose  end  of  the  casing  is  slightly  twisted — an  essential  proce- 
dure— and  is  then  secured  'by  a  thread  on  the  outer  side  of  the 
tube.  If  properly  made,  the  valve  will  work  freely  without  vibra- 
tion, and  the  opening  be  sufficiently  large  to  allow  a  good  current  of 
air  to  pass.  It  should  collapse  instantly  and  be  air  tight  when  the 
current  of  air  is  reversed.  The  back  lash,  or  lag  of  closure,  of  these 
valves  is  extremely  small,  and  they  will  open  or  close  with  a  pres- 
sure of  air  not  exceeding  the  pressure  changes  in  normal  respira- 
tion. When  not  in  use,  the  valves  should  be  kept  in  glycerine  water 
on  ice.  Valves  prepared  in  this  way  have  been  in  use  a  month  with- 
out loss  of  efficiency.  They  are,  however,  made  with  so  great  ease 
that  new  valves  are  provided  for  each  subject,  and  they  are  there- 
fore especially  adapted  to  ward  work  (Fig.  71). 

"The  valves  are  inserted  in  reverse  order  into  a  supporting  metal 
T-piece,  and  the  joints  made  air-tight  by  tape.  The  stem  of  the 
T  is  connected  with  the  mouthpiece.  Through  a  rubber  tube  of 
about  3/4  inch  bore,  the  expired  air  is  collected  in  the  spirometer, 
or  Douglas  Bag. 

"3.  THE  TISSOT  SPIROMETER  is  pictured  in  Fig.  72.  We  have 
found  the  100-liter  size  to  be  very  serviceable  in  the  clinic.  This 
instrument  is  mounted  on  a  platform  having  rubber  wheels,  and  can 
be  moved  about  the  wards  with  ease.  The  bell  of  the  spirometer  is 
made  of  aluminum  and  is  suspended  in  a  water-bath  between  the 
double  walls  of  a  hollow  cylinder  made  of  galvanized  iron.  The 


372 


BLOOD   AND   URINE    CHEMISTRY 


height  of  the  bell  is  72  cm.  and  the  diameter  42  cm.    An  opening 
at  the  bottom  of  the  cylinder  connects  through  a  three-way  stop- 


Fig.    72. — The    Tissot    spirometer.      In    actual    experiment,    subject    is    reclining 
down   and   the    valves  and    mouthpiece   are   held   with   a   clamp. 


lying 


cock  with  the  rubber  tube  leading  from  the  expiratory  valve  of  the 
mouthpiece  (see  Fig.  70).  The  bell  is  counterpoised  by  means  of  a 
weight.  In  the  original  Tissot  spirometer  an  automatic  adjustment 


BASAL    METABOLISM  373 

permitted  water  in  amount  equal  to  the  water  displaced  by  the  bell 
to  flow  from  the  spirorneter  cylinder  into  a  counterpoise  cylinder 
as  the  bell  ascended  out  of  the  water.  The  bell,  being  heavier  out 
of  water  than  when  it  is  immersed,  is  accordingly  counterpoised  in 
any  position,  although,  Carpenter  has  shown  that  this  refinement 
is  unnecessary.  An  opening  in  the  top  of  the  spirometer  permits 
the  insertion  of  a  rubber  stopper,  through  which  are  passed  a  ther- 
mometer, a  water  manometer,  and  a  stopcock  with  tube  for  drawing 


Fig.  73. — The  Douglas  bag  method  for  determining  the  respiratory  exchange.  The  ar- 
rangement of  mouthpiece,  valves,  and  connecting  tubes  shown  here  has  been  found  to  be 
more  convenient  than  that  recommended  by  Douglas. 

the  sample  of  air.    A  scale  on  the  side  of  the  instrument  gives  the 
volume  of  the  air. 

"During  an  observation  the  subject  sits  in  a  reclining  position 
or  lies  upon  a  couch.  When  the  bell  of  the  spirometer  is  placed  at 
zero,  the  mouthpiece  adjusted  in  the  mouth,  and  the  nose  clamped, 


374  BLOOD   AND   URINE    CHEMISTRY 

respiration  is  started,  the  expirations  being  passed  through  the 
stopcock,  which  is  so  turned  as  to  allow  them  to  pass  to  the  outside 
air.  After  a  few  minutes  the  stopcock  is  turned  so  that  the  expira- 
tions are  passed  into  the  spirometer  for  a  definite  length  of  time. 
At  the  end  of  the  period  the  cock  is  again  turned,  and  after  the 
barometric  pressure,  temperature,  and  volume  of  the  air  have  been 
noted,  the  composition  of  the  air  is  determined  in  the  Haldane  gas 
analysis  apparatus. 

"4:.  THE  DOUGLAS  BAG. — The  Douglas  bag  is  made  of  rubber- 
lined  cloth,  and  is  capable  of  holding  from  50  to  100  liters.  It  is 
especially  useful  for  investigations  during  exercise,  since  it  is  fitted 
with  straps  so  that-  the  bag  can  be  fastened  to  the  shoulders  (Fig. 
73).  It  is  then  connected  with  the  valves,  the  mouthpiece  of  which 
is  placed  between  the  lips.  Respirations  are  commenced  writh  the 
three-way  valve  turned  so  as  to  allow  the  expirations  to  pass  di- 
rectly outside.  After  respiratory  equilibrium  is  established,  the 
three-way  valve  is  turned  during  an  inspiratory  period  so  that  the 
succeeding  expirations  may  pass  into  the  bag.  The  time  required 
to  fill  the  bag  comfortably  is  determined  with  a  stop-watch.  The 
air  which  has  been  collected  in  the  bag  during  the  period  is  thor- 
oughly mixed  and  passed  through  a  meter,  the  temperature  and 
barometric  pressure  are  noted,  and  a  sample  analyzed  in  the  Hal- 
dane gas  apparatus.  The  bag  should  be  emptied  completely  by 
rolling  it  up  when  nearly  empty. 

"5.  The  Haldane  Gas-analysis  Apparatus.  PRINCIPLE. — The 
Haldane  method  of  analysis  of  expired  air  is  simple  and  easily 
learned.  The  apparatus  (Fig.  74)  consists  of  a  gas  burette,  a  con- 
trol burette  of  the  same  size  (both  surrounded  with  a  water  jacket), 
and  bulbs  containing  dilute  caustic  potash  or  soda  solution  for  the 
absorption  of  the  carbon  dioxide  and  an  alkaline  pyrogallate  solu- 
tion for  the  absorption  of  the  oxygen.  The  gas  burette  is  connected 
with  the  bulbs  by  a  two-way  stopcock,  which  allows  a  sample  of 
gas  to  pass  into  either  bulb.  A  control  tube  (10}  is  put  into  con- 
nection with  the  burette  through  a  manometer  tube,  which  is  con- 
nected with  the  alkali  bulb,  and  can  be  made  to  compensate  for  any 
changes  in  temperature  that  may  occur  during  the  course  of  the 
analysis.  For  an  analysis  the  gas  is  transferred  to  the  burette  from 
the  sampling  tube,  saturated  with  water  vapor  over  mercury,  and 
then  measured,  after  which  it  is  transferred  into  the  caustic  solu- 


BASAL    METABOLISM 


375 


the  loss  of  volume  due  to  CO,  absorption.  It  is  then  transferred 
into  the  alkaline  pyrogallate  solution,  which  frees  it  from  oxygen, 
after  which  it  is  again  brought  back  to  the  burette  to  determine  the 
loss  in  volume  due  to  the  absorption  of  the  oxygen. 


Fig.  74. — Haldane  gas  apparatus  (A)  and  Pearce  sampling  tube   (B). 

"THE  APPARATUS. — The  detail  of  the  Haldane  apparatus  is  shown 
in  the  accompanying  cut.  The  measuring  burette  (1)  holds  21  c.c. 
The  bulb  is  of  15  c.c.  capacity,  and  the  graduated  stem,  which  is 
about  4  mm.  in  bore  and  60  cm.  in  length,  is  graduated  to  0.01  c.c. 
from  15  c.c.  to  21  c.c.  The  stopcock  at  the  top  of  the  burette  is 
double-bored,  so  that  in  one  position  air  can  be  drawn  in  from  a 


376  BLOOD   AND   URINE  .CHEMISTRY 

gas  sampler  (2}  and  in  another  sent  into  the  absorption  bulbs  (3}. 
The  lower  part  of  the  burette  extends  through  the  rubber  cork  at 
the  bottom  of  the  water  jacket  (4).  A  piece  of  rubber  tubing  is  at- 
tached to  the  bottom  of  the  burette  and  is  passed  through  a  metal 
tube,  furnished  on  its  inside  with  a  metal  disc  which  presses  against 
the  rubber  tubing,  the  pressure  being  controlled  by  means  of  a  fine 
adjusting  screw  (6).  Below  this  a  glass  stopcock  (7)  connects  with 
rubber  tubing  to  the  mercury  leveling  bulb  (5).  The  absorption 
bulb  for  C02,  containing  20  per  cent  NaOH  or  KOH  (9),  is  put  in 
connection  with  the  burette  by  suitably  turning  stopcocks  (3  and 
8).*  The  control  burette  (10)  is  also  in  connection  with  this  bulb 
through  the  manometer  tube  (11)  t  Any  variation  in  temperature 
which  may  occur  during  the  analysis  will  cause  the  level  of  the 
alkaline  solution  in  the  manometer  to  change. 

"When  final  readings  of  the  shrinkage  of  volume  arc  made,  the 
level  of  the  caustic  solution  is  returned  to  the  level  of  that  in  the 
manometer.  By  so  doing  any  error  due  to  temperature  changes  is 
avoided,  since  change  in  temperature  must  be  equal  in  the  two 
burettes. 

"The  absorption  bulb  for  oxygen  (12}  is  filled  with  a  solution 
made  by  dissolving  10  grams  of  pyrogallic  acid  in  100  c.c.  of  a  nearly 
saturated  KOH  solution.  The  specific  gravity  of  the  KOH  should 
be  1.55,  which  is  obtained  approximately  by  dissolving  the  sticks 
(pure  by  alcohol)  in  an  equal  weight  of  water.  The  mark  (13}  on 
the  stem  of  the  bulb  indicates  the  level  at  which  the  solutions  should 
stand.  Enough  pyrogallate  solution  is  introduced  through  tube 
15  to  fill  bulbs  12  and  14  two-thirds  full.  Then  pyrogallate  solu- 
tion is  poured  into  tube  16  until  the  difference  in  level  of  the  fluids 
is  sufficient  to  produce  enough  pressure  to  raise  the  level  of  the 
pyrogallate  solution  in  12  to  the  level  13  on  the  stem.  Stopcock 
8  must  be  open  during  this  procedure.  It  may  be  necessary  to  add 
or  take  away  a  little  pyrogallate  solution  through  15  to  attain  the 
above  level. 

"Care  must  be  taken  to  allow  for  complete  absorption  of  oxygen 
from  the  air  that  is  entrapped  between  14  and  16  before  an  anal- 
ysis is  made ;  otherwise  changes  will  be  produced  in  the  level  of  the 
pyrogallate  solution.  The  air  in  the  capillary  tubing  connecting 

*The  stopcock  (8)  is  double-bored,  so  that  the  tube  leading  from  the  burette  can  be 
brought  into  connection  with  either  9  or  12.. 

tThis  tube  also  has  a  three-way  stopcock  (79),  so  that  it  may  be  opened  to  the  outside. 


BASAL    METABOLISM  377 

the  burettes  with  the  absorption  bulbs  must  also  be  freed  of  CO2 
and  02.  This  can  be  accomplished  by  making  a  dummy  analysis  of 
atmospheric  air  before  the  real  analysis.  Great  care  must  be  taken 
to  have  atmospheric  pressure  in  all  the  tubes  at  the  start  of  the 
analysis.  This  is  accomplished  by  opening  the  stopcock  in  the 
burette  first  to  atmospheric  air  and  then  to  the  absorption  bulbs, 
until  no  further  change  in  the  level  of  the  fluids  in  the  stems  of  the 
absorption  bulbs  occurs.  This  level  is  then  marked  and  used  as 
the  standard.  A  small  amount  of  water  in  the  burette  over  the 
mercury  assures  a  saturation  of  the  air  with  water  vapor.  Time  for 
drainage  must  be  allowed  before  making  readings. 

"A  very  serviceable  sampling  tube  for  the  transfer  of  air  can  be 
made  from  a  30  c.c.  ground-glass  syringe,  to  which  is  attached  a 
two-way  stopcock.  A  cut  of  this  is  shown  in  Fig.  74.  The  dead 
space  in  these  syringes  is  washed  out  by  working  the  piston  back 
and  forth  several  times.  A  thin  coating  of  vaseline  prevents  leak- 
age of  the  gas.  We  have  found  that  these  sampling  tubes  will 
retain  a  sample  of  expired  air  without  change  up  to  eight  hours. 

"  MANIPULATION  or  APPARATUS. — The  sampling  syringe  (20)  is 
attached  to  opening  2  of  the  burette,  and  its  stopcock  (17)  opened 
to  atmospheric  air.  The  level  of  the  mercury  is  raised  to  the  level 
of  the  stopcock  of  the  syringe  and  is  then  turned  so  that  syringe  and 
burette  are  in  communication.  The  bulb  of  mercury  is  lowered 
so  that  the  mercury  falls  in  the  burette.  This  draws  the  piston  of 
the  syringe  with  it,  and  fills  the  burette  with  air  from  the  syringe. 
It  is  advisable  to  put  a  little  positive  pressure  on  the  piston  of  the 
syringe  in  the  maneuver  to  prevent  possible  leakage.  When  all  of 
the  air  is  in  the  burette  a  slight  positive  pressure  is  produced  in 
the  burette  by  gently  pressing  on  the  piston,  and  immediately  there- 
after the  stopcock  on  the  syringe  (17)  is  again  turned  to  the  orig- 
inal position.  This  allows  the  pressure  of  air  in  the  burette  to 
come  to  that  of  the  atmosphere.  The  height  of  the  mercury  is  now 
adjusted  to  a  convenient  height  in  the  burette  by  closing  cock  7  and 
turning  the  milled  screw  6.  The  cock  18  is  now  made  to  communi- 
cate with  the  absorption  bulbs.  If  the  air  in  the  burette  is  at  at- 
mospheric pressure,  no  change  will  occur  in  the  level  of  the  fluids. 
The  reading  is  then  taken  on  the  burette. 

"The  next  step  in  the  analysis  consists  in  turning  stopcock  8  to 
communicate  with  the  caustic  soda  solution  in  bulb  9,  and  the 


378  BLOOD   AND   URINE    CHEMISTRY 

leveling  tube  (5)  is  raised,  forcing  mercury  into  the  burette  and 
the  air  into  bulb  9.  The  gas  is  passed  back  and  forth  several  times 
until  absorption  is  complete,  as  can  be  determined  by  the  fact  that 
the  level  of  the  mercury  in  the  burette  remains  constant  when  the 
fluid  in  the  bulb  is  returned  to  its  original  level  (13)  on  the  stem. 
In  this  adjustment  it  is  convenient  to  make  the  gross  leveling  by 
the  mercury  bulb  and  the  fine  leveling  by  closing  7  and  turning  6 
until  the  fluid  in  9  is  at  the  original  height.  The  reading  on  the 
burette  indicates  the  loss  in  volume  due  to  the  C02  absorbed. 

"The  oxygen  is  removed  by  a  similar  procedure,  the  gas  being 
passed  into  the  alkaline  pyrogallate  solution  by  turning  cock  8  to 
communicate  with  bulb  12.  The  absorption  of  oxygen  is  slower 
than  for  C02,  and  more  care  must  be  taken  to  get  complete  absorp- 
tion. The  air  in  the  tubing  between  the  fluid  in  9  and  stopcock  8 
must  be  washed  out  several  times  in  order  to  get  the  oxygen  which 
is  left  in  it  after  the  absorption  of  the  C02.  "When  this  is  complete, 
the  final  reading  on  the  burette  is  made  and  the  loss  in  volume 
from  the  second  reading  represents  the  oxygen. 

"THE  CALCULATIONS 

"The  calculation  of  tlie  percentile  composition  of  the  air  and  of 
the  respiratory  quotient  is  represented  in  the  following  example  of 
an  actual  analysis: 

11  (The  temperature  and  barometric  pressure  as  taken  at  the  time 
of  the  experiment  were  20°  C.  and  747  mm.  Hg.) 

C02  analysis — 

1st  reading  of  burette   

2nd  reading  of  burette  after  absorption  of  CO,.  .... 


CO2  absorbed    0.80 

0.80  -f-  20  =  4.0  per  cent  CO,  in  expired  air. 

02  analysis — 

2nd  reading  of  burette  19.20 

3rd  reading  of  burette  after  absorption  of  O2 15.90 


O2  absorbed    3.30 

3.30  -=-  20  =  16.50  per  cent  of   O,  in  expired  air. 

Determination  of  R.Q. — 

O2  in  atmospheric  air=  20.94% 

O,-CO,  in  expired  air   (16.50  +  4)  =  20.50% 


100  -  20.94  =  79.06%,*N  in   atmospheric  air. 
100-20.50  =  79.50%,    N    in    expired    air. 


'This  is  the  constant  O  percentage  in  air. 


BASAL    METABOLISM  379 

"Since  the  nitrogen  is  not  changed  in  volume,  the  last  figure 
shows  that  more  oxygen  must  have  been  taken  in  during  inspiration 
than  0,  +  C02  has  been  given  back  in  expiration.  This  obviously 
must  be  taken  into  account  in  the  calculations.  The  amount  of  O 
actually  inspired  for  each  100  c.c.  of  air  expired  is  found  as  follows : 

20.94    (%    O,    in    atmospheric    air) 

„-   -  .. 7— ; =r^ — : ; : :— -       X   <9.oO      (%      N-     Ill     expired     E1TJ  .'      OT 

79.06    (%    N2   in   atmospheric   air) 

0.265  (constant  factor  x  79.5  (%  N  found  for  this  observation)  =  21.07,  the 
volume  of  O2  which  would  have  been  present  in  expired  air  to  account  for  N 
present.* 

21.07-16.50  =  4.57%   O,  actually  absorbed. 
4.00-0.03  (CO2  in  inspired  air)  =3.97%  CO.,  excreted. 
3.97 
.'.-j-=  =  0.87,   the   respiratory  quotient,   or  ratio   of   (XX  excreted   to   O, 

absorbed. 

"Total  Gas  Exchange. — The  volume  of  air  expired  in  15  minutes 
into  the  Tissot  spirometer  was  found  to  be  100  liters  measured  at 
20°  C.  and  747  mm.  Hg.  (brass-scale  barometer).  This  volume  of 
gas  must  be  corrected  so  as  to  give  the  volume  of  dry  air  at  0°  and 
760  mm.  Hg.  To  do  this  two  things  must  be  taken  into  account. 
(1)  Since  the  expired  air  is  saturated  with  water,  the  pressure 
due  to  water  vapor  must  be  subtracted  from  the  observed  baro- 
metric pressure  to  obtain  the  true  pressure.  The  vapor  tension 
of  water  for  various  temperatures  is  given  in  Table  2  on  page 
380.  (2)  The  barometer  tube  lengthens  or  contracts  with  heat  or 
cold,  and  therefore  the  barometric  readings  must  be  corrected. 
The  corrections  for  ordinary  barometric  readings  are  found  in 
Table  3,  page  381.  The  figure  corresponding  to  the  temperatures 
is  subtracted  from  the  barometric  reading  in  order  to  obtain  correct 
barometric  pressure. 

"In  the  above  experiment,  the  correction  for  the  barometer  is 
2.41  mm.  (see  Table  3,  page  381),  and  that  for  vapor  tension  at 
20°  C.  is  17.4  (see  Table  2,  page  380). 

"Actual  Barometric  Pressure. — 747  -  (17.5  +  2.39)  =  727.21  mm. 
The  coefficient  of  expansion  of  gases  is  taken  as  0.003665)  or  1/273  ; 
therefore  the  volume  of  0°  equals  the  volume  at  1°  divided  by 
1  -  0.003665  t;  and  hence 


*This  calculation  can  be  simplified  by  using  an  abbreviated  table   (page  380)   giving  the 
Oo   figure  corresponding  to  the   various  percentages  of  N   in  the   expired  air. 


380  BLOOD'  AND  URINE  CHEMISTRY 

_ .  and  V  = 

273  +  t          1 +  0. 003665  t 
Volume  at  t°. 

VP 
The  volume  of  gas  being  inversely  as  the  pressure,  \o  =  -^— ,  \vhere  V  = 

volume  at  P  pressure;  or  working  both  corrections  together, 

VP  x  273  VP 

Vo  = 


bOx(273-ft)         7(30  (1-f  0.00c665  t) 
"This  formula  applied  to  the  present  problem  reads: 

100x727.2 


760  (1  +  0.003665x20) 

"The  latter  calculation  can  be  considerably  simplified  by  using 
standard  tables  which  give  constants  for  corrections  of  gas  vol- 
umes. These  are  easily  obtainable  and  are  given  in  part  in  Table 
IV. 

"According  to  these  tables  for  20°  C.  and  727.21  mm.  Hg.  B.P., 
the  factor  is  0.89124;  therefore: 

0.89124  x  100  =  89.124  liters,  0°C.  and  760  mm.  Hg. 

0.89124  x  4.57  =  40.7  liters  of  O2  in  15  min.,  or  16.28  L.  per  hour. 

"The  Caloric  Value  Calculated  from  the  Gas  Exchange.  —  By 
reference  to  Table  V  giving  the  heat  value  of  1  liter  of  02  at  various 
respiratory  quotients,  it  is  found  that  at  a  R.Q.  of  0.87,  4.888  cal- 
ories are  expended  ;  16.28  liters  of  02  is  therefore  equivalent  to 
18.4  x  4.888  =  79  calories. 

'  '  The  results  must  be  calculated  for  surface  area  as  well  as  body 
weight.  Suppose  the  subject  weighed  85  kg.  and  was  170  cm.  in 
height  ;  by  reference  to  the  chart  for  determining  the  surface  area 
of  man  (page  355),  this  would  be  found  to  be  1.96  square  meters. 
The  caloric  expenditure  per  square  meter  in  the  above  case  is 

79 

therefore—  —=  40.3  calories. 
1.96 

TABLE  1 

THE  PERCENTAGE  OF  OXYGEN  WHICH  is  EQUIVALENT  TO  THE  NITROGEN  FOUND 
IN  THE  EXPIRED  AIR 

To  obtain  the  nitrogen  in  the  expired  air,  add  the  percentage  of  CO2  and 
O2  found  and  subtract  the  sum  from  100.  The  table  gives  the  percentage  for 
O2  corresponding  to  this  figure: 

%X3      78.7  78.8  78~79  79.0  7971  79.2  79.3  79.4       7971       79.6       79.7       79.8 

%O2     20.86  20.88  20.90  20.93  20.96  20.98  21.01  21.04     21.07     21.10     21.12     21.14 

79.9  80.0  80.1  80.2  80.3  80.4  80.5  80.6 

21.16  21.19  21.22  21.25  21.28  21.31  21.35  21.38 


BASAL    METABOLISM  381 

TABLE  2 
TENSION  OF  AQUEOUS  VAPOB  IN  MILLIMETERS  OF  MERCURY 

To  obtain  the  dry  barometer  pressure,  subtract  the  mm.  Hg.  corresponding 
to  the  temperature  of  the  air  from  the  barometer  pressure  at  the  time  of 
the  experiment: 

Temp.    T5°    16°    17°    18°    19°    20°    21°    22°    23°    24°   ,.  25° 
Mm.     12.7    13.5    14.4    15.4    163    17.4    18.5    19.7    20.9    22.2    23.5 

TABLE  3 

TEMPERATURE  CORRECTIONS  TO  REDUCE  READINGS  OF  A  MERCURIAL  BAROMETER 
WITH  A  BRASS  SCALE  TO  0°C. 

Subtract  the  appropriate  quantity  as  found  in  table  from  the  height  of 
the  barometer.  The  table  is  for  a  barometer  with  a  brass  scale,  and  the 
values  are  a  little  lower  (about  .2  mm.)  than  for  the  glass  scale.  The  cor- 
rections for  intermediate  temperatures  can  be  approximated. 


Temp. 

.  700 
mm. 

710 
mm. 

720 
mm. 

730 
mm. 

740 
mm. 

750 
mm. 

760 
mm. 

770 
mm. 

15° 
20° 
25° 

1.69 
2.26 

2.83 

1.72 
^  22 

2.87 

1.74 
2.32 

2.91 

1.77 
2.36 
2.95 

1.79 
2.39 

2.99 

1.81 
2.42 
3.03 

1.84 
2.45 
3.07 

1.86 
2.48 
3.11 

TABLE  4 

TABLE  FOR  REDUCING  GASEOUS  VOLUMES  TO  NORMAL  TEMPERATURE  AND  PRES- 
SURE 

The  observed  volume,  when  multiplied  by  the  factor  corresponding  to  the 
temperature  and  pressure,  will  give  the  volume  of  the  expired  air  reduced  to 
0°  and  760  mm. 


Aim. 

15° 

16° 

17° 

18° 

19° 

20° 

21° 

22° 

23° 

24° 

25° 

720 
730 
740 
750 
760 
770 

.898 
.910 
.922 
.935 
.947 
.960 

.894 
.907 
.919 
.932 
.944 
.957 

.891 
.904 
.916 
.928 
.941 
.953 

.888 
.901 
.913 
.925 
.938 
.950 

.885 
.897 
.910 
.922 
.934 
.948 

.882 
.S94 
.907 
.919 
.931 
.945 

.880 
.891 
.904 
.916 
.928 
.940 

.877 
.888 
.901 
.913 
.925 
.936 

.873 
.885 
.897 
.910 
.922 
.933 

.870 
.882 
.894 
.907 
.919 
.930 

.867 
.879 
.891 
.904 
.916 
.927 

So-called  basal  metabolism  is,  therefore,  a  rather  constant  quan- 
tity. Eliminate  the  food  metabolism  by  starving  your  patient 
twelve  hours,  eliminate  the  metabolism  of  muscular  effort  by  keep- 
ing the  patient  in  a  recumbent  position,  you  will  have  left  only 
the  energy  output,  the  metabolism  of  circulatory  and  respiratory 
mechanism,  with  a  small  amount  for  those  negligible  changes  within 
the  cells  of  the  body  while  the  body  is  resting.  This  is  the  basal 
metabolism  which  we  can  estimate ;  it  is  quite  constant  for  the  same 
individual. 


382 


BLOOD    AND    URINE    CHEMISTRY 


The  estimation  of  basal  metabolism  in  thyroid  disease  as  noted 
before  is  of  inestimable  value  in  studying  this  disease.  Factors 
to  be  taken  into  account  always  in  using  basal  metabolism  figures 
in  diagnosis  are:  first,  fever.  Fever  is  accompanied  by  an  in- 
creased metabolic  rate.  In  the  dyspneic  state  in  cardiac  decompeii- 


TABLE 

5 

B.Q. 

CALOUIES  FOB  1  LITER  O,      RELATIVE  CALORIES  CONSUMED  AS 

Number               Carbohydrate                     Fat 
per  cent                       per  cent 

0.70 

4.68(5 

0 

100 

0.71 

4.690 

1.4 

98.6 

0.72 

4.702 

4.8 

95.2 

0.73 

4.714 

8.2 

91.8 

0.74 

4.727 

11.6 

88.4 

0.75 

4.739 

15.0 

85.0 

0.76 

4.752 

18.4 

81.6 

0.77 

4.764 

21.8 

•78.2 

0.78 

4.776 

25.2 

74.8 

0.79 

4.789 

28.6 

71.4 

0.80 

4.801 

32.0 

68.0 

0.81 

4.813 

35.4 

64.6 

0.82 

4.825 

38.8 

61.2 

0.83 

4.838 

42.2 

57.8 

0.84 

4.850 

45.6 

54.4 

0.85 

4.863 

49.0 

51.0 

0.86 

4.875 

52.4 

47.6 

0.87 

4.887 

55.8 

44.2 

0.88 

4.900 

59.2 

40.8 

0.89 

4.912 

62.6 

37.4 

0.90 

4.924 

66.0. 

34.0 

0.91  • 

4.936 

69.4 

30.6 

0.92 

4.948 

72.8 

27.2 

0.93 

4.960 

76.2 

23.8 

0.94 

4.973 

79.6 

20.4 

0.95 

4.985 

83.0 

17.0 

0.96 

4.997 

86.4 

33.6 

0.97 

5.010 

89.8 

10.2 

0.98 

5.022 

93.2 

6.8 

0.99 

5.034 

96.6 

3.4 

1.00 

5.047 

100.0 

0.0 

(From  Lusk.) 

sation,  there  is  a  rise  in  the  basal  metabolism  due  probably  to  the 
increased  muscular  action  arising  from  the  dyspneic  state.  In 
edematous  states  the  metabolism  is  lowered,  owing  to  the  water- 
logged tissues  interfering  with  the  interchange  of  metabolites. 
While  Macleod  states  above  that  in  pernicious  anemia  the  metab- 
olism is  normal,  Meyer  and  Du  Bois1  state  that  it  is  increased.  It 


'Meyer  and   Du  Hois:      (Arch.   Tnt.   Med.,   May,   1917,   xvi 


BASAL    METABOLISM  383 

is  high  in  leucemia.2  It  is  to  be  remembered  that  an  increase  of 
from  7  to  23  per  cent  occurs  after  the  ingestion  of  7  to  10  grains  of 
caffeine,  so  coffee  must  be  interdicted  before  making  these  tests.3 

Means4  sums  up  the  points  of  usefulness  of  the  respiration  ap- 
paratus as  follows : 

"1.  Basal  metabolism  can  be  readily  studied  in  a  hospital  clinic 
with  comparatively  inexpensive  apparatus. 

"2.  The  normal  basal  metabolism  is  a  fairly  constant  affair, 
and  hence  wide  variations  from  it  in  disease  are  of  interest  to 
the  clinician. 

"3.  A  marked  rise  occurs  in  hyperthyroidism. 

"4.  A  marked  fall  occurs  in  hypothyroidism. 

"5.  In  regard  to  hyperthyroidism,  it  seems  probable  that  the 
basal  metabolism  furnishes 

"  (a)  The  best  index  as  to  the  severity  of  the  disease,  and  hence 
is  a  quantitative  means  of  following  the  course  and  of  judging  the 
effectiveness  of  treatment;  and 

"  (b)  A  valuable  aid  in  differential  diagnosis. 

"6.  Enormous  grades  of  obesity  are  possible  in  the  presence  of 
a  normal  basal  metabolism. 

"7.  "When  a  reduction  in  the  metabolism  was  found  in  obese 
subjects,  there  was  also  clinical  evidence  of  defective  internal 
secretion. 

"8.  A  clearer  conception  of  food  requirements  in  disease  is  fur- 
nished by  the  basal  metabolism  than  any  other  factor." 

While  most  of  the  data  upon  which  these  conclusions  were  based 
were  obtained  by  the  use  of  very  elaborate  apparatus,  at  the  pres- 
ent time  those  who  wish  to  take  up  this  work  can  obtain  a  Tissot 
apparatus  manufactured  in  this  country5  at  a  comparatively  mod- 
erate figure,  and  thus  carry  out  this  kind  of  investigation. 


=Murphy,   Means,   and   Aub:     Arch.   Int.   Med.,   May,    1917,  xix,   890. 
"Means,"  J.  II.,  Aub.  J.  C.,  Du  Bois,  E.  P.:     Arch.  Int.  Med.,  May,   1917,  832. 
4Means:      Boston  Med.  &   Surg.  Jour.,   June   15,    1916. 
5Sanborn    Company,    Boston,    Mass. 


384  BLOOD  AND  URINE  CHEMISTRY 

The  authors  are  fortunate  in  having  secured  from  Drs.  Win. 
Engelbach  and  John  L.  Tierney  of  St.  Louis,  in  the  form  of  a 
personal  communication,  as  yet  unpublished,  data  on  their  studies 
of  internal  secretory  disorders.  These  two  investigators  are  well 
known  for  their  original  work  on  the  diagnosis  and  treatment 
of  diseases  of  the  ductless  glands,  and  the  data  they  submit  in 
connection  with  basal  metabolism  represent  the  product  of  their 
daily  examinations  of  these  interesting  cases.  We  desire  to  thank 
them  for  the  privilege  of  presenting  this  entirely  new  material 
to  our  readers  in  advance  of  its  publication  through  the  journal 
channels.  Their  communication  follows: 

"Independently  of  foreign  observation,  there  has  been  a  tre- 
mendous amount  of  work  done  by  American  investigators  in  the 
determination  of  basal  metabolism  in  both  health  and  disease. 
The  researches  of  Lusk,  Du  Bois,  Means,  Peabody,  Carpenter, 
Benedict,  Gephart,  Aub,  Tomkins,  and  others,  are  well  known  to 
workers  in  this  fascinating  field.  Means,  Du  Bois,  McCaskey, 
Plummer,  and  others  have  given  special  attention  to  the  fluctua- 
tions of  basal  metabolism  in  thyroid  states,  and  the  invariable 
conclusion  has  been  that  the  basal  metabolism  of  the  individual  is 
the  best  index  to  thyroid  activity,  and,  furthermore,  to  the  effi- 
cacy of  the  various  types  of  treatment.  Careful  comparisons  have 
been  made  between  the  methods  of  direct  and  indirect  calorim- 
etry,  and  the  consensus  of  opinion  is  that,  although  indirect 
calorimetry  is  of  a  lesser  degree  of  accuracy,  it  is  sufficiently  pre- 
cise for  all  clinical  purposes.  Struck  by  the  tremendous  value 
of  basal  metabolism  determinations  in  the  diagnosis,  prognosis, 
and  index  to  treatment  of  thyroid  disease,  we  made  it  a  part  of 
our  routine  study  of  all  endocrine  disturbances.  The  instrument 
Ave  have  used  has  been  the  Benedict  portable  respiration  appara- 
tus. In  our  calculations,  we  have  followed  the  Linear  Formula 
of  Du  Bois  and  Du  Bois,  and  the  graduated  table  of  average 
calories  per  square  meter  of  body  surface  per  hour  for  age  and 
sex,  of  Aub  and  Du  Bois.  In  the  following  series  of  cases  we  have 
appended  tables  of  sugar  tolerance  determinations.  The  blood 
sugar  was  estimated  in  the  postabsorptive  state,  after  fifteen  hours ' 
fast.  One  and  fifty-nine  hundredths  grams  of  glucose  per  kilo- 
gram of  body  weight  were  given,  and  a  blood  sugar  estimation 
was  made  at  the  end  of  one  hour,  and  again  at  the  end  of  two 


BASAL    METABOLISM 


385 


hours.  With  some  trepidation,  we  adopted  an  arbitrary  normal 
curve:  before  the  ingestion  of  glucose,  from  0.10  to  0.13  per  cent; 
at  the  end  of  the  first  hour,  0.18  per  cent ;  at  the  end  of  the  second 
hour,  0.15  per  cent.  A  decreased  tolerance  was  considered  one  which 
would  produce  a  higher  curve  during  the  two  hours '  estimation  than 
the  norm.  An  increased  tolerance  would  show  figures  below  this 
standard  curve.  Under  ordinary  circumstances,  we  would  expect 
an  increased  basal  metabolism  to  be  associated  with  a  decreased 
sugar  tolerance,  and  vice  versa.  In  the  appended  tables  many 
discrepancies  in  this  respect  will  be  noted,  and  we  are  inclined 
to  accept  the  basal  metabolic  reading  as  the  more  accurate  index 
to  glandular  activity,  and  believe  that  the  sugar  tolerance  de- 
termination alone  as  an  index  to  endocrinous  physiologic  activity 
will  never  be  of  more  than  questionable  value  until  it  is  properly 
correlated  by  some  suitable  collateral  determination  of  blood 
volume. 

"The  cases  studied  have  been  arranged,  according  to  their 
clinical  diagnoses,  in  the  following  groups :  polyglandular  insuffi- 
ciency, polyglandular  hyperactivity,  hyperthyroidism,  hypothy- 
roidism,  hypopituitarism  (anterior  lobe  and  bilobar),  and  hyperpit- 
uitarism. 

POLYGLANDULAR  INSUFFICIENCY 


DIAGNOSIS 

BASAL    METABOLISM 

SUGAR   TOLERANCE 

i  Eunuchoidism 

+8%  (two  readings) 

.104 

.261       .222 

1. 

[  Gigantism 

+20% 

(decreased) 

(  Pituitary                                   +4% 

.110 

.159       .141 

2>       ]  Gonad 

(increased) 

i  Pituitary                                 -28% 

.110 

.180       .120 

».- 

I  Gonad 

(normal) 

(  Pituitary 

+1% 

.110 

.180       .120 

4. 

[  Gonad 

(normal) 

(  Thyroid 

-23%  (before  treatment) 

.120 

.246       .180 

5. 

\  Pituitary 

1-10%  (after  treatment) 

(decreased) 

Pituitary 

-8% 

6. 

Thyroid 

Gonad 

1 

Pituitary 

-25% 

.136 

.231       .153 

Thyroid 

(decreased) 

(  Pituitary 

-11% 

.098 

.252       .141 

8. 

\  Gonad 

(decreased) 

386 


BLOOD  AND  URINE  CHEMISTRY 

P'OLYGLANDULAR   INSUFFICIENCY    (CONT'D) 


DIAGNOSIS 

BASAL   MKTABOLISM 

SUGAR 

TOLERANCE 

9. 

(Thyroid   (On 
|  Pituitary 

treatment)      -1% 

.130 

.219          .099 

(decreased) 

It'. 

i  Thyroid 
]  Gouad 

+33% 

.117 

.195       .162 
(  decreased  ) 

11. 

(  Thyroid 
j  Pituitary 

+.1% 

.119 

.176       .160 
(normal) 

12. 

(  Thyroid 
|  Pituitary 

-8% 

.130 

.219       .207 
(decreased) 

1  ° 

(  Tliyroid 
]  Pituitary 

-\% 

.132 

.180       .150 
(normal) 

14. 

(Thyroid  (On 
}  Gonad 

treatment;    +10<7< 

.096 

.10         .084 
(increased) 

15. 

I  Thyroid 
]  Gonad 

-4% 

.120 

.144       .111 
(increased) 

16. 

(Pituitary 
I  Gonad 

-16% 

.102 

.129       .120 
(increased) 

17. 

i  Pituitary 
j  Thyroid 

-5% 

.144 

.162       .130 
(increased) 

18. 

(  Thyroid 
/  Gonad 

-12% 

iy. 

(  Thyroid 
J  Gonad 

-13% 

.080 

.133       .10 
(increased) 

[  Adrenal 

20. 

(  Pituitary 
/  Thyroid 

-5% 

.120 

.192       .213 
(decreased) 

21. 

(  Pituitary 
j  Thyroid 

+7% 

.132 

.150       .120 
(increased) 

9  2 

(Pituitnry 
j  Thyroid 

-.8% 

.090 

.096       .111 
(increased) 

(  Pituitary 

-11% 

.081 

.141       .096 

_.). 

/  Thyroid 

(increased) 

"It  will  be  noted  that  in  the  cases  of  polyglandular  insufficiency, 
the  basal  metabolism  has  been  consistently  decreased,  a  few  cases, 
however,  showing  a  definite  increase.  We  wish  to  make  special 
mention  of  the  cases  showing  discrepancy.  Case  1  was  typically 
a  pituitary  giant,  whose  hyperactivity  we  judged  was  beginning 
to  pass  over  into  a  state  of  hypoactivity,  and  whose  basal  metab- 


BASAL   METABOLISM  387 

olism,  in  two  determinations,  showed  a  definite  increase,  being, 
we  believe,  presumptive  evidence  that  his  pituitary  gland  was 
still  physiologically  hyperactive.  Case  1.0  showed  marked  hor- 
monic  signs  of  eunuchoidism,  associated  with  a  diabetes  insipidus, 
which  we  presumed  to  be  a  pituitary  insufficiency.  The  patient 
showed  a  basal  metabolism  of  -f-  33  per  cent,  and  it  may  be  inter- 
esting to  note  that  he  is  one  of  but  two  cases  of  diabetes  insipidus 
in  our  series  of  eleven,  who  did  not  respond  to  pituitary  treat- 
ment. Case  14,  a  combination  of  thyroid  and  gonad  insufficiency, 
showed  a  basal  metabolism  of  -f-  10  per  cent,  but  this  reading 
was  made  after  thyroid  had  been  administered  over  a  considera- 
ble period  of  time.  Cases  2  and  21,  showing  moderate  increases 
in  basal  metabolism,  were,  judging  from  their  hormonic  signs, 
glandular  insufficiencies,  and  we  have  no  adequate  explanation  for 
the  increased  metabolism. 

POLYGLANDULAR     HYPERACTIVITT 


DIAGNOSIS 

BASAL    METABOLISM 

SUGAR 

TOLERANCE 

(  Thyroid 

-5% 

.105 

.156       .171 

i. 

j  Pituitary 

(decreased) 

(  Pituitary 

+42% 

.080 

.160       .110 

*• 

j  Thyroid 

(increased) 

(  Pituitary 

-1% 

.116 

.148       .132 

3 

}  Thyroid 

(increased) 

(  Pituitary 

+11% 

4. 

^  Thyroid 

"Cases  2  and  4,  showing  definitely  increased  basal  metabolism, 
had  characteristic  hormonic  signs  of  both  pituitary  and  thyroid 
hyperactivity.  Cases  1  and  3  showed  minor  signs  of  hyperactiv- 
ity,  but  showed  moderate  decreases  in  basal  metabolism.  Clini- 
cally, the  hormonic  signs  of  the  latter  were  very  much  less 
marked. 


888 


BLOOD  AND  URINE  CHEMISTRY 

HYPERTHYROIDISM 


BAS 

5AL    METABOLISM 

SUGAR   TOLERANCE 

1. 

+18% 

.086       .128       .088 

(increased) 

2. 

+2% 

.110       .20         .190 

(decreased) 

3. 

+72% 

4. 

-2% 

.128       .130       .136 

(increased) 

5. 

+46% 

.120       .222       .180 

(decreased) 

G.      (Clinical    hyper-) 

-12% 

.114       .168       .110 

(increased) 

7. 

+39% 

.132       .276       .222 

(decreased) 

8. 

+19% 

.096       .118       .112 

(increased) 

9. 

-10% 

10. 

+22% 

11. 

+36% 

12. 

Normal 

13. 

450% 

14.      (Toxic   adenoma) 

+1% 

.114       .129       .106 

(increased) 

15. 

+13% 

18.      (Postoperative) 

-2% 

17. 

(-19% 

18.     (Postoperative) 

+80% 

19. 

+24% 

20. 

+18% 

21. 

+103% 

.090       .147       .13.r, 

(increased) 

BASAL    METABOLISM  389 

HYPERTHYROIDISM    (CONT'D) 

BASAL    METABOLISM  SUGAR   TOLERANCE 

22.  +20%  .078       .114       .086 

(increased) 

23.  +14%)    lt 

(two  readings) 


24.  +12% 

25.  +30% 


+15%  .080       .105       .090 

(increased) 


"In  the  foregoing  list  of  26  cases  of  hyperthyroidism,  very  few 
discrepancies  are  to  be  noted.  Case  6;  one  of  the  borderline  type, 
presented  a  somewhat  clearly  cut  clinical  picture  of  hyperthy- 
roidism. The  basal  metabolism  showed  a  —  12  per  cent,  with  an 
increased  sugar  tolerance.  Case  9,  at  the  time  of  observation,  pre- 
sented a  doubtful  clinical  picture,  with  a  basal  metabolism  of 
—  10  per  cent.  The  subsequent  course,  however,  has  led  us  to 
believe  the  case  to  have  been  hypothyroid,  rather  than  hyperthy- 
roid. 

HA'POTHYROIDISM 


BASAL    METABOLISM 

SUGAR 

TOLERANCE 

1. 

+15% 

2. 

-13% 

.122 

.148       .110 

(increased) 

3. 

-15% 

.114 

.184       .174 

(decreased) 

4. 

-23% 

.108 

.118       .118 

(increased) 

5. 

-21%] 
-12%)    (two  readlllgs) 

.102 

.118       .104 
(increased) 

6. 

-28% 

.10 

.148       .146 

(increased) 

7. 

+5% 

.108 

.130       .126 

(increased) 

8. 

-18% 

BLOOD  AND  URINE  CHEMISTRY 
HYPERTHYROIDISM    (CONT'D) 


BASAL    METABOLISM 

SUGAR   TOLERANCE 

9. 

-1% 

10.      (Slight) 

+4% 

11. 

-7% 

.090       .159       .111 

(increased) 

12. 

-13% 

.081       .120       .144 

(increased) 

13. 

-13% 

.090       .110       .090 

(increased) 

14.     (On  treatment) 

+11% 

.087       .222       .170 

(decreased) 

15. 

+4% 

.120       .219       .222 

(decreased) 

16.      (Clinical  hypo-) 

+19% 

.128       .150       .124 

(increased) 

17. 

+.2% 

.123       .186       .186 

(decreased) 

18. 

-5% 

.086       .071       .080 

(increased) 

"The  foregoing  table  shows  rather  a  consistent  decrease,  with 
an  occasional  discrepancy.  Case  1  presented  definite  hormonic 
signs  of  hypothyroidism,  and,  despite  an  increased  basal  metab- 
olism, was  placed  upon  thyroid  therapy,  with  gratifying  clinical  re- 
sponse. Case  14  was  classically  a  hypothyroid  type,  but  at  the  time 
of  increased  determination  of  +  H  per  cent,  had  been  on  thyroid 
treatment.  Case  16  was  clinically  a  hypothyroid  type,  but  showed 
a  basal  metabolism  of  -f-  19  per  cent.  The  subsequent  course  of 
this  case  is  not  known. 

HYPOPITUITARISM 


BASAL    METABOLISM 

SUGAR   TOLERANCE 

1.     (Anterior  lobe) 

+14% 

.120         .160 

(2nd  hr.) 

(decreased) 

2.              " 

-.3% 

.102       .180       .120 

(normal) 

-30%     (before  treatment) 
+.8%  (after   treatment) 


BASAL    METABOLISM  391 

HYPOPITUITARISM   (CONT'D) 

BASAL  METABOLISM  SUGAR  TOLERANCE 

4.     (Anterior  lobe)  +4%  .096       .10         .070 

(increased) 


6. 

"           " 

+15% 

(On  treatment) 

7. 

(Bilobar) 

+2% 

.108       .138       .114 

(increased) 

8. 

t  « 

-22% 

.105       .129       .128 

(increased) 

9. 

" 

+9% 
,-,0«/      (two    readings) 

+iZ7o 

.138       .252       .237 
(decreased) 

10. 

<  < 

-.2% 

11. 

» 

-16% 

.120       .156       .147 

(increased) 

"The  majority  of  cases  of  clinical  hypopituitarism  showed  a 
decreased  basal  metabolism.  Case  1,  although  presenting  many 
of  the  hormonic  signs  of  anterior  lobe  insufficiency,  displayed  an 
increase  in  basal  metabolism  of  -|-  14  per  cent.  Case  6,  showing 
an  increase  of  -f~  15  per  cent,  had  received  considerable  treat- 
ment. Case  3  showed  a  —  30  per  cent  before  treatment,  and 
a  -f  .8  per  cent  after  one  month's  treatment.  Case  9,  who  was 
classified  upon  the  general  physical  findings  as  hypopituitarism, 
showed  an  increased  basal  metabolism  in  two  different  observa- 
tions. 

HYPERPITUITARISM 

BASAL  METABOLISM  SUGAR  TOLERANCE 

T.     (Posterior  lobe)  +4%  .128       .30         .136 

(decreased) 
2.     (Bilobar)  -12% 

"Case  2  shows  a  basal  metabolism  of  —  12  per  cent,  but 
there  was  every  clinical  reason  to  believe  that,  although  this 
patient  had  primarily  been  of  the  hyperactive  type,  there  had 
been  a  definite  transposition  into  a  state  of  hypoactivity,  as  man- 
ifested by  the  mental  state,  muscular  fatigability,  loss  of  libido, 


392  BLOOD  AND  URINE  CHEMISTRY 

and  many  minor  signs  of  decreased  function.  His  primary  hy- 
peractivity  persisted  in  the  form  of  gross  physical  changes  of 
the  osseous  system,  sella  turcica,  etc. 

''In  conclusion,  we  believe  that  basal  metabolism  determinations 
are  destined  to  become  an  integral  part  of  diagnostic  procedure, 
not  only  in  the  measurement  of  thyroid  activity,  but  in  the  deter- 
mination of  pluriglandular,  pituitary,  and  possibly  gonadal  ac- 
tivity as  well.  Hitherto,  wre  have  been  accustomed  to  base 
our  diagnosis  of  endocrinous  disorders  largely  upon  "hormonic 
signs"  and  symptoms  or  physical  changes,  such  as  gross  changes 
in  the  osseous  and  genital  systems  and  the  coarser  manifestations 
of  metabolic  perversion  such  as  obesity.  It  must  be  remembered 
that  the  physical  characteristics  or  hormonic  signs  give  evidence 
of  certain  endocrinous  states ;  but  it  also  must  be  recalled,  as 
Marie  long  ago  pointed  out,  that  a  hyperactive  state  may  be  trans- 
formed into  a  hypoactive  state,  retaining  the  physical  character- 
istics of  hyperactivity,  but  possessing  the  physiologic  functions 
of  hypoactivity.  The  basal  metabolism  will  enable  us,  we  believe, 
to  determine  the  physiologic  activity  of  certain  glands  at  the  time 
of  observation,  independently  of  what  their  previous  activities 
may  have  been.  This  determination  of  physiologic  activity  at 
the  time  of  observation  is  of  paramount  importance,  because  it  is, 
we  believe,  the  most  reliable  index  to  diagnosis,  prognosis,  and 
what  is  of  equal  importance,  proper  substitutional  therapy. 


APPENDIX 

FOLIN'S  NEW  METHODS 

The  early  setting  up  for  this  second  edition  prevented  us  from 
inserting  into  each  chapter  some  important  facts  on  the  methods 
which  were  brought  out  by  Folin  and  Wu  in  the  Journal  of  Biolog- 
ical Chemistry,  1919,  xxxviii,  No.  1.  This  matter  we  deem  of  suffi- 
cient importance  to  be  used  as  an  appendix  of  the  present  edi- 
tion. The  essential  feature  of  the  new  methods  by  Folin  and  Wu 
is  that  a  much  smaller  quantity  of  blood  is  required  for  making 
a  complete  analysis.  We  also  believe  that  the  new  method  de- 
scribed by  them  for  the  estimation  of  nonprotein  nitrogen  is 
better  than  the  methods  hitherto  in  vogue.  The  other  methods 
for  the  other  ingredients  are  said  by  these  workers  to  give  slightly 
more  reliable  results,  although  we  have  been  well  satisfied  with 
our  results  obtained  by  the  methods  before  described.  The  color- 
imeter used  with  these  methods  is  either  the  Bock-Benedict  or 
the  Duboscq.  It  is  undoubtedly  true  that  the  obtaining  of  a 
protein-free  filtrate  suitable  for  the  largest  possible  number  of 
different  determinations  is  the  ideal  method. 

Folin  also  points  out  that  he  has  for  some  years  doubted  the 
full  trustworthiness  of  the  uric  acid  determinations.  He  has 
therefore  developed  a  modification  of  the  Folin-Denis-Benedict 
method  which  requires  the  filtrate  from  only  2  c.c.  of  blood.  He 
has  also  solved  the  problem  of  keeping  standard  uric  acid  solu- 
tions and  has  elaborated  a  new  method  for  the  determination  of 
sugar  in  the  blood.  All  the  determinations,  nonprotein  nitrogen, 
urea,  creatinine,  creatine,  uric  acid  and  sugar,  can  be  determined 
from  10  c.c.  of  blood. 

Folin  and  Wu  use  a  new  protein  precipitant,  namely,  tungstic 
acid.  It  possesses  the  advantage  that  only  a  small  quantity  is 
required,  the  precipitation  is  more  complete  than  that  produced 
by  10  gm.  of  trichloracetic  acid  and  the  filtrate  obtained  gives 
no  trouble  in  connection  with  any  of  the  determinatives  so  far 
investigated.  Neither  creatinine  nor  uric  acid  is  carried  down  by 
the  precipitate. 

393 


394  BLOOD  AND  URINE  CHEMISTRY 

The  new  precipitant  is  used  as  follows: 

1.  Draw  10  c.c.  of  blood  into  a  bottle  in  the  manner  already  in- 
dicated, using  potassium  or  sodium  oxalate.    Defibrinate. 

2.  Pipette  5  c.c.  of  this  into  a  small  Erlenmeyer  flask  Contain- 
ing 35  c.c.  distilled  water.     Shake  until  hemolysis  is  complete. 

3.  Add  5  c.c.  10  per  cent  sodium  tungstate  solution  and  shake. 
Add  5  c.c.  of  2/3  normal  sulphuric  acid  and  shake  while  adding — 
this  produces  tungstic  acid  which  precipitates  the  protein.   Shake 
vigorously  for  one  half  minute  and  let  stand  until  it  becomes 
a  chocolate  color.    Note:    If  there  is  no  excess  of  oxalate,  it  will 
not  foam  on  shaking,  foam  meaning  an  incomplete  precipitation 
of  protein. 

4.  Filter  through  filter  paper  into  a  Pyrex  test  tube  of  200 
mm.  x  25  mm.  dimensions. 

5.  Pipette  5  c.c.  filtrate  containing  0.5  c.c.  blood  into  a  Pyrex 
tube. 

6.  Add  1  c.c.  digestion  mixture  and  boil  until  it  turns  brown 
or  black. 

7.  Boil  over  a  small  flame  BB  microburner  and  when  white 
fumes  of  sulphuric  acid  begin  to  rise,  cover  with  watch  glass 
and  continue  boiling  until  solution  turns  clear  again. 

8.  Add  35  c.c.  distilled  water  to  digested  filtrate. 

9.  Add  15  c.c.  Nessler  solution.    This  is  now7  our  unknown  non- 
protein  nitrogen. 

10.  Set  standard  at  20  with  the  Duboscq  or  Bock-Benedict  color- 
imeter. 

11.  Fill  the  cell  of  the  Bock-Benedict  colorimeter  with  stand- 
ard solution. 

12.  Fill  cup  with  the  unknown. 

13.  Make  reading  as  follows: 

Standard    Known 
—  =  Unknown 

Reading  x 

For  Example:     Standard  is  20,  known  solution  contains  25 
mgms.  of  nitrogen  per  100  c.c.    Say  reading  is  15. 
20    25 

—  x  —  =33.3  mgms.  nitrogen  per  100  c.c.  blood 
15     x 


APPENDIX  395 

Reagents 

Reagents  used  in  Folin's  new  method  of  estimation  of  non- 
protein  nitrogen  are  as  follows : 

1.  Digestion  Mixture. — Mix  concentrated  sulphuric  acid,  100 
c.c.  with  phosphoric  acid  syrupy  (85  per  cent)  300  c.c.    Let  stand 
one  week.    Of  this  mixture  take  100  c.c.  and  add  to  it 

Copper  sulphate,  6%  solution,     10  c.c. 
Water  100  c.c. 

2.  Standard   Ammonium   Sulphate    Solution.— CP   ammonium 
sulphate  must  be  used  and  solution  so  made  that  10  c.c.  contains 
0.5  mgms.  of  nitrogen.     This  is  equivalent  to  0.2  gm.  per  liter. 

Make  the  ammonium  sulphate  solution  by  adding  0.2  gm.  am- 
monium sulphate  to  1000  c.c.  water  and  make  the  standard  from 
this  as  needed  from  time  to  time  as  follows: 

3.  Standard  Solution  Ammonium  Sulphate. — 

Ammonium  sulphate  solution  (above)  5  c.c. 

Digestion  mixture  2  c.c. 

Distilled  water  50  c.c. 

Nessler's  sol  30  c.c. 

Distilled  water  to  make  100  c.c. 

4.  Nessler's  Solution. — 

Stock  Nessler  750  c.c. 

Sodium  hydroxide  10%     3500  c.c. 
Water  750  c.c. 

5.  Stock  Nessler  Solution. — Dissolve  150  gms.  potassium  iodide 
and  110  gms.  of  iodine  in  a  500  c.c.  Florence  flask ;  add  100  c.c. 
water  and  an  excess  of  metallic  mercury,  140  to  150  gm.    Shake 
the  flask  vigorously  and  continuously  for  7  to  15  minutes  or  until 
the  dissolved  iodine  has  nearly  disappeared.     The  solution  be- 
comes quite  hot.    When  the  red  iodine  solution  has  begun  to  visi- 
bly pale,  though  still  red,  cool  in  running  water  and  continue  the 
shaking  until  the  reddish  color  of  the  iodine  has  been  replaced 
by  the  greenish  color  of  the  double  iodide.    This  whole  operation 
usually  does  not  take  more  than  15  minutes.     Separate  the  solu- 
tion from  the  surplus  mercury  by  decantation  and  washing  with 
liberal   quantities   of   distilled  water.     Dilute   the   solution   and 
washings  to  a  volume  of  2  liters.    If  the  cooling  is  begun  in  time, 
the  resulting  reagent  is  clear  enough  for  immediate  dilution  with 


396  BLOOD  AND  URINE  CHEMISTRY 

10  per  cent  alkali  and  water,  and  the  finished  solution  can  be 
used  at  once  for  Nesslerizations.  This  process  gives  one  a  better 
Nessler  than  is  obtainable  by  the  older  method,  owing  to  the 
fact  that  the  mercuric  iodide  obtainable  from  dealers  frequently 
contains  insoluble  impurities  which  make  it  difficult  to  obtain 
a  clear  solution  by  the  addition  of  potassium  iodide. 

Determination  of  Urea  by  Urease  Decomposition  and  Distillation 

Folin's  method  makes  use  of  a  preparation  of  the  jack  bean 
urease  instead  of  the  purified  or  concentrated  urease  now  on  the 
market.  This  is  made  as  follows:  Transfer  to  a  200  c.c.  flask 
or  bottle  about  3  gm.  of  permutit  powder.  Wash  this  by  decanta- 
tion,  once  with  2  per  cent  acetic  acid,  then  twice  with  water. 
Add  to  the  moist  permutit  powder  100  c.c.  of  30  per  cent  alcohol 
(35  c.c.  of  95  per  cent  alcohol  mixed  with  70  c.c.  water).  Then 
introduce  5  gms.  of  jack  bean  meal  and  shake  for  10  minutes. 
The  Arlington  Chemical  Company  supplies  jack  bean  meal  in  a 
finer  state  of  division  than  one  can  readily  make  by  hand.  Fil- 
ter and  collect  the  filtrate  in  three  or  four  clean  small  bottles. 
Set  one  aside  for  immediate  use ;  it  will  remain  serviceable  for 
one  week  at  room  temperature  if  not  exposed  to  direct  sunlight. 
Put  the  others  on  ice  where  they  will  remain  good  for  three 
to  five  weeks.  The  filtrate  contains  all  of  the  urease  and  is  very 
active. 

Method  of  Determination  of  Urea. — Take  5  c.c.  of  the  tungstic 
acid  filtrate  to  a  clean  and  dry  Pyrex  test  tube  of  75  c.c.  capacity. 
Do  not  use  a  tube  that  has  been  used  for  any  other  purpose.  Add 
2  drops  of  pyrophosphate  solution  (140  gms.  of  sodium  pyrophos- 
phate  IISP  and  20  gs.  glacial  phosphoric  acid  to  the  liter).  Add 
0.5  to  1  c.c.  of  the  urease  solution  above  described,  immerse  in 
beaker  of  warm  water  for  five  minutes.  Beaker  temperature 
is  never  to  exceed  55°  C. 

Distill  the  ammonia  into  2  c.c.  of  0.05  normal  hydrochloric 
acid  contained  in  a  second  test  tube.  (See  Fig.  75-A  for  arrange- 
ment.) This  is  done  by  heating  over  a  microburner,  with  a  rub- 
ber stopper  perforated,  with  a  glass  tubing  arrangement  leading 
off  into  the  second  test  tube.  This  test  tube  which  acts  as  a  re- 
ceiver is  held  in  place  by  means  of  a  rubber  stopper  in  the  side 


APPENDIX 


397 


of  which  a  notch  has  been  cut  to  permit  the  escape  of  air  and 
some  steam.  The  delivery  tube  must  extend  below  the  surface  of 
the  hydrochloric  acid  before  the  distillation  is  begun. 

Add  to  the  hydrolyzed  blood  filtrate  a  dry  pebble,  2  c.c.  satu- 
rated borax  solution,  and  a  drop  or  two  of  paraffin  oil.  Insert 
firmly  the  stopper  carrying  both  delivery  tube  and  receiver,  and 
boil  moderately  fast  over  a  microburner  for  4  minutes.  Size  of 


Fig.    75. — A.   At   beginning   of   distillation.      B.   Toward   end   of   distillati 


the  flame  should  never  be  cut  down  during  distillation,  neither 
should  the  boiling  be  so  brisk  that  the  emission  of  steam  from 
the  receiving  tube  begins  before  the  end  of  3  minutes.  At  the 
end  of  4  minutes  slip  off  the  receiver  from  the  rubber  stopper 
and  put  it  into  the  position  of  Fig.  75-B.  Continue  the  distillation 
for  1  minute  more  and  rinse  off  the  lower  outside  part  of  the 
delivery  tube  with  a  little  water.  Cool  the  distillate  with  run- 
ning water,  dilute  to  20  c.c.  and  add  2.5  c.c.  Nessler  solution 
as  described  under  nonprotein  nitrogen  technic  above.  Fill  to  the 
25  c.c.  mark  and  compare  in  the  colorimeter  with  a  standard 
containing  0.3  mg.  of  nitrogen  in  a  100  c.c.  flask  and  Nesslerized 


398  BLOOD  AND  URINE  CHEMISTRY 

with  10  c.c.  of  the  Nessler  solution.  Nesslerize  the  unknown 
and  standard  as  simultaneously  as  possible.  Example :  Multiply 
20,  the  height  of  the  standard,  by  15  and  divide  by  the  colori- 
metric  reading  to  get  the  urea  nitrogen  per  100  c.c.  of  blood. 
In  order  to  prevent  bumping,  the  Pyrex  tube  should  be  absolutely 
dry  or  rinsed  with  alcohol  before  using. 

Estimation  of  Creatinine  by  Folin  Method 

Place  25  or  50  c.c.  of  a  saturated  solution  of  purified  picric 
acid  in  a  clean,  small  flask,  add  5  or  10  c.c.  of  10  per  cent  sodium 
hydroxide,  and  mix.  Add  10  c.c.  of  the  blood  filtrate  to  a  small 
flask  or  test  tube,  transfer  5  c.c.  of  the  standard  creatinine  solu- 
tion to  another  flask,  and  dilute  the  standard  to  20  c.c.  Standard 
creatinine  solution  for  this  modification  by  Folin  is  made  by 
adding  1  gm.  of  pure  creatinine  in  N/10  normal  hydrochloric  acid 
and  making  up  to  a  liter  with  distilled  water.  Each  c.c.  of  this 
contains  1  mgm.  creatinine.  Then  add  5  c.c.  freshly  prepared 
alkaline  picrate  solution  to  the  blood  filtrate  and  10  c.c.  of  the 
diluted  creatinine  solution.  Let  stand  for  8  to  10  minutes.  Make 
the  color  comparison  in  the  usual  manner.  The  color  compari- 
son should  be  completed  within  15  minutes  from  the  time  the 
alkaline  picrate  solution  was  added ;  it  is  therefore  advisable  nev- 
er to  work  with 'more  than  three  or  four  samples  at  a  time. 

Example:  Eeading  of  the  standard  in  mm.  usually  20,  is  mul- 
tiplied by  1.5,  3,  4.5  or  6,  according  to  how  much  of  the  stand- 
ard was  used,  and  divided  by  the  reading  of  the  unknown,  in  mm. 
gives  the  amount  of  creatinine  in  mgm.  per  100  c.c.  of  blood.  In 
connection  with  the  calculation  it  is  to  be  noted  that  the  stand- 
ard is  made  up  to  twice  the  volume  of  the  unknown  so  that  each 
5  c.c.  of  the  standard  creatinine  solution,  while  containing  0.03 
mg.  corresponds  to  0.015  mgm.  in  the  blood  filtrate. 

Determination  of  Uric  Acid 

Solutions  required  in  this  new  method : 

1.  Standard  uric  acid  sulphite  solution.  Folin  claims  the  keep- 
ing power  of  this  standard  solution  of  uric  acid  is  greater  than 
that  of  any  other  method.  The  solvent  is  10  per  cent  sodium 
sulphite  and  the  keeping  quality  of  the  solution  depends  upon  the 


APPENDIX  399 

fact  that  the  sulphite  keeps  the   solution  free  from   dissolved 
oxygen.    It  is  prepared  as  follows : 

Make  1  to  3  liters  of  a  20  per  cent  solution  of  sodium  sulphite, 
let  stand  overnight  and  filter.  Dissolve  1  gm.  of  uric  acid  in  125 
c.c.  to  150  c.c.  of  0.4  per  cent  lithium  carbonate  solution  and  dilute 
to  a  volume  of  50  c.c.  Transfer  50  c.c.,  corresponding  to  100  mg. 
of  uric  acid,  to  each  of  a  series  of  volumetric  liter  flasks.  Add 
200  to  300  c.c.  water,  then  500  c.c.  filtered  20  per  cent  sodium 
sulphite  solution,  and  finally  make  up  to  volume,  and  mix  well. 
Fill  a  series  of  200  c.c.  bottles,  and  stopper  very  tightly  with 
rubber  stoppers.  The  solution  which  is  in  a  bottle  that  is  opened 
daily  will  keep  three  or  four  months.  In  unopened  bottles 
Folin  states  that  it  will  keep  for  years.  The  surplus  20  per  cent 
sulphite  solution  should  be  diluted  to  a  concentration  of  10  per 
cent  and  should  then  be  transferred  to  a  series  of  small  tightly 
stoppered  bottles.  This  sulphite  is  added  to  the  unknown  to 
offset  the  sulphite  content  of  the  standard. 

2.  A  10  per  cent  sodium  sulphite  solution,  just  described.    Two 
c.c.  of  this  is  used  for  each  determination. 

3.  A  5  per  cent  sodium  cyanide  solution,  to  be  added  from  a 
burette,  2.5  to  5  c.c.  for  each  series  of  determinations. 

4.  A  10  per  cent  solution  of  sodium  chloride  in  0.1  normal 
hydrochloric  acid  (10  to  20  c.c.  used  for  each  series  of  determina- 
tions). 

5.  The   uric   acid  reagent  prepared   according   to   Folin   and 
Denis. 

A  still  stronger  reagent  is  obtained  by  heating  the  sodium 
tungstate  100  gm.  and  the  phosphoric  acid  80  c.c.  plus  water 
700  c.c.  for  24  hours  instead  of  2  hours ;  but  the  advantage  gained, 
about  20  per  cent,  is  not  needed.  Dilute  the  solution  to  one  liter. 

6.  A  solution  of  5  per  cent  silver  lactate  in  5  per  cent  lactic 
acid,  4  to  5  c.c.  needed  for  each  determination. 

In  making  the  estimation,  we  use  20  c.c.  of  the  blood  filtrate 
corresponding  to  2  c.c.  of  blood.  To  10  c.c.  of  the  filtrate  de- 
scribed under  the  determination  of  nonprotein  nitrogen,  that  is 
10  c.c.  in  each  of  two  centrifuge  tubes,  add  2  c.c.  of  a  5  per  cent 
solution  of  silver  lactate  in  5  per  cent  lactic  acid,  stir  with  a  very 
fine  glass  rod.  Centrifuge;  add  a  drop  of  silver  lactate  to  the 
supernatant  fluid  Avhich  should  be  almost  perfectly  clear  and 


400  BLOOD  AND  URINE  CHEMISTRY 

should  not  become  turbid  when  the  last  drop  of  silver  solution  is 
added.  Remove  the  supernatant  fluid  by  decantation  as  com- 
pletely as  possible.  Add  to  each  tube  1  c.c.  of  a  solution  of  10 
per  cent  sodium  chloride  in  0.1  normal  hydrochloric  acid  and  stir 
thoroughly  with  a  glass  rod.  Then  add  5  to  6  c.c.  of  water,  stir 
again,  and  centrifuge  once  more.  By  this  chloride  treatment  the 
uric  acid  is  set  free  from  the  precipitate.  Transfer  the  two 
supernatant  fluids  by  decantation  to  a  25  c.c.  volumetric  flask. 
Add  1  c.c.  of  the  10  per  cent  sulphite  solution,  0.5  c.c.  of  a  5 
per  cent  solution  of  sodium  cyanide  and  3  c.c.  of  a  20  per  cent 
solution  of  sodium  carbonate.  Prepare  simultaneously  two  uric 
acid  solutions  as  follows: 

Transfer  to  one  50  c.c.  volumetric  flask  1  c.c.,  and  to  another 
50  c.c.  flask  2  c.c.  of  the  standard  uric  acid  sulphite  solution. 
To  the  first  flask,  add  1  c.c.  of  the  10  per  cent  sulphite  solution. 
Then  add  to  each  flask  4  c.c.  of  the  acidified  sodium  chloride 
solution,  1  c.c.  of  the  sodium  cyanide  solution  and  6  c.c.  of  the 
sodium  carbonate  solution.  Dilute  with  water  to  about  45  c.c. 
When  the  two  standard  solutions  and  the  unknown  have  been 
prepared  as  described,  they  are  ready  for  the  addition  of  the 
uric  acid  reagent  of  Folin  and  Denis.  Add  0.5  c.c.  of  this  reagent 
to  the  unknown  and  1  c.c.  to  each  of  the  standards  and  mix.  Let 
stand  for  10  minutes,  fill  to  the  mark  with  water,  mix  and  make 
the  calculation  by  color  comparison. 

Calculation:  Note  that  the  blood  filtrate  corresponds  to  2  c.c. 
of  blood;  that  the  standard  is  diluted  to  twice  the  volume  of  tho 
unknown  and  that  the  standard  contains  0.1  or  0.2  mg.  of  uric 
acid.  Blood  filtrate  from  blood  containing  2.5  mg.  of  uric  acid 
will  be  just  equal  in  color  to  the  weaker  standard.  Twenty  times 
2.5  divided  by  the  reading  of  the  unknown  gives  the  uric  acid 
content  of  the  blood  when  the  weaker  standard  is  set  at  20.  Note 
also  that  the  uric  acid  reagent  must  be  added  invariably  after 
and  not  before,  the  addition  of  the  sodium  carbonate,  because 
in  acid  solutions  the  sulphite  will  give  a  blue  color  with  the  phos- 
photungstic  acid. 

Determination  of  Blood  Sugar 

Folin  claims  that  the  last  modification  by  Benedict  of  his 
method  and  Myers'  modification  of  the  original  Benedict  method  as 


APPENDIX  401 

previously  described  by  us,  gives  invariably  results  that  are  ma- 
terially higher  than  his  new  methods. 

Solutions  Required  for  This  New  Method. — 

1.  Standard  sugar  solution.    Dissolve  1  gm.  of  pure  anhydrous 
dextrose  in  water  and  dilute  to  a  volume  of  100  c.c.    Mix,  add  a 
few  drops  of  xylene  or  toluene,  and  bottle.     If  pure  dextrose 
is  not  available,  a  standard  solution  of  invert  sugar  made  from 
cane  sugar  is  equally  useful.    Transfer  exactly  1  gm.  of  cane  sugar 
to  a  100  c.c.  volumetric  flask;  add  20  c.c.  of  normal  hydrochloric 
acid  and  let  the  mixture  stand  overnight  at  room  temperature 
or  rotate  the  flask  vigorously  for  10  minutes  in  a  water  bath  kept 
at  70°  C.    Add  1.68  gm.  of  sodium  bicarbonate  and  about  0.2  gm. 
of  sodium  acetate,  to  neutralize  the  hydrochloric  acid.     Shake 
a  few  minutes  to  remove  most  of  the  carbonic  acid,  and  fill  to  the 
100  c.c.  mark  with  water.    Then  add  5  c.c.  more  water  (1  gm.  of 
cane  sugar  yields  1.05  gm.  of  invert  sugar)  and  mix. 

Transfer  to  a  bottle,  add  a  few  drops  of  xylene  or  toluene  and 
shake  well,  stopper  tightly.  The  stock  solution  made  in  either 
way  keeps  indefinitely.  Dilute  5  c.c.  to  500  c.c.,  giving  a  solution 
10  c.c.  of  which  contains  1  gm.  of  dextrose  or  invert  sugar.  Add 
some  xylene.  Use  2  c.c.  for  each  determination. 

2.  Alkaline  copper  solution.    Dissolve  40  gms.  of  anhydrous  so- 
dium carbonate  in  about  400  c.c.  water  and  transfer  to  a  liter 
flask.    Add  7.5  gms.  tartaric  acid  and  when  the  latter  is  dissolved, 
add  4.5  gms.  of  crystallized  copper  sulphate;  mix,  make  up  to 
a  volume  of  one  liter.     If  the  carbonate  used  is  impure,  a  sedi- 
ment will  develop  in  the  course  of  a  week  or  two.    If  this  hap- 
pens, decant  into  a  second  bottle. 

3.  Phosphotungstic-phosphomolybdic  acid :    Transfer  to  a  large 
flask  25  gms.  of  molybdenium  trioxide  or  34  gms.  of  ammonium 
molybdate,  add  140  c.c.  of  10  per  cent  sodium  hydroxide  and  about 
150  c.c.  water.    Boil  for  20  minutes  to  drive  off  the  ammonia.    Add 
to  the  solution  100  gms.  of  sodium  tungstate,  50  c.c."  of  85  per 
cent  phosphoric  acid  and  100  c.c.  of  concentrated  hydrochloric 
acid.    Dilute  to  a  volume  of  700  to  800  c.c.,  close  the  mouth  of 
the  flask  with  a  watch  glass  and  funnel.     Boil  gently  for  not 
less  than  4  hours,  adding  hot  water  from  time  to  time  to  replace 
that  lost  by  boiling.     Cool  and  dilute  to  1  liter.     This  solution 


402  BLOOD  AND  URINE  CHEMISTRY 

is  identical  with  the  phenol  reagent  of  Folin  and  Denis.  For 
use  in  connection  with  this  determination  of  blood  sugar,  dilute  1 
volume  (100  c.c.)  of  the  reagent  with  one  half  volume  (50  c.c.) 
of  water  and  one  half  volume  (50  c.c.)  of  concentrated  hydro- 
chloric acid. 
4.  Saturated  sodium  carbonate  solution. 

Determination  of  Sugar 

"  Heat  a  beaker  of  water  to  vigorous  boiling.  Transfer  2  c.c. 
of  tungstic  acid  blood  nitrate  to  a  test  tube  20  x  200  mm.  grad- 
uated -to  25  c.c.  Transfer  2  c.c.  of  the  dilute  standard  sugar 
solution  to  another  test  tube.  Add  to  each  tube  2  c.c.  of  the  al- 
kaline copper  tartrate  solution.  Heat  in  the  boiling  water  for 
6  minutes.  Remove  the  test  tubes  and  add  at  once  without  cooling, 
preferably  from  a  graduated  pipette,  1  c.c.  of  the  strongly  acidi- 
fied and  diluted  phenol  reagent.  Do  this  as  nearly  simultaneously 
as  possible.  The  hydrochloric  acid  is  used  to  dissolve  the  copper 
oxide.  Mix,  cool,  add  5  c.c.  of  saturated  sodium  carbonate.  An 
intense  blue  color  is  developed  which  will  last  several  days.  Di- 
lute the  contents  of  the  tubes  to  the  25  c.c.  mark,  and  after  at 
least  5  minutes  make  the  color  comparison  in  the  usual  manner. 
Example. — The  depth  of  the  standard  in  mm.  multiplied  by  100 
and  divided  by  the  reading  of  the  unknown,  gives  the  sugar  con- 
tent in  mg.  per  100  c.c,  of  blood. 


GENERAL  INDEX 


Accessory  solution  for  test  for  phos- 
phates, in  general  analysis  of 
urine,  118 
Ace-acetic  acid,  determination  of,  in 

blood,  77 
Acetone,  110 
and  acetoacetic  acid,  113 
bodies  in  urine,  111 

in   urine,   factors   for  calculating 

results,  116 

in  urine,  simultaneous  determina- 
tions of  total,  113 
in   urine,   Van   Slyke   and   Fitz's 

method  in,  111 
determination  of,  in  blood,  77 
Acetone,  test  for,  in  general  analy- 
sis of  urine,  118 
Acid  sodium  urate  crystals,  138 
Acidity  of  urine,  total,   88 
Aeidosis : 

apparatus  used  in  tests,  61,  64 
bicarbonate  of  sodium  in,  237,  246 
.bichemistry  of,  (Henderson),  259 
cases  studied,  23,9 
consumption    of    fats   injurious    in, 

236 

controls    of    Marriott,    Levy,    and 
Bowntree's    method    for    de- 
termination  of   hydrogen-ion 
concentration  of  blood,  71 
definition     of     acidosis     given     by 

Naunyn,  249 
determination   of,  333 
determination  of  the  alkali  reserve 

of  the  blood  plasma,  73 
example    of    reading    on    the    Van 

Slyke  apparatus,   68 
fasting  and  diet  in,  251 

403 


Acidosis — Cont  'd 

Friderici^ 's  method  for  determina- 
tion of  carbon  dioxide  in 
alveolar  air,  241 

Henderson  and  Palmer's  experi- 
ments showing  magnitude  of 
alkali,  248 

in  acute  and  chronic  diseases,  258 

in  diabetes,  258 

in  infants,   234,  257 

introduction  of  alkalies  in,  234 

kidney,  lung  and  blood  functions  in 
relation  to,  260 

Levy,  Marriott,  and  Kowntree's 
method  for  the  determina- 
tion of  the  hydrogen-ion  con- 
centration of  the  blood,  68 

lipemia,  248 

nephritis  in,  252 

over  5.0  mgms.  of  creatinine  in 
blood  denotes  fatal  end  of 
any  case,  212 

preparation  of  sacks  for  method,  70 

preparation  of  salt  solution,  74 

preparation  of  standard  colors,  69 

producing  acidosis  in  dogs,  250 

results  obtained  in  normal  individ- 
uals, 75 

results  of  study  in  normal  and  path- 
ological cases,  239 

salt  solution  used  in  method  of  test, 
68 

technie  of  method  for  test,  68 

tests  for,  61 

Van  Slyke  method  for  determination 
of  carbon  dioxide  combining 
power  of  blood  plasma,  61, 
243 

Van  Slyke  method  simplest,  244 


404 


GENERAL    INDEX 


Adrenal  bodies  in  glycogenolysis  and 

glycosuria,  183 
Age,  influence  of,  on  energy  balance, 

306 
Albumin,    general    analysis    of    urine, 

108 

Heller's  nitric  acid  test,  108 
Robert's  test  for,  108 
Alkali   reserve    of    blood   plasma,    de- 
termination of,  73 
Alumina  cream,  preparation  of,  37 
Ambard  coefficient,   296 
Ammonia: 

aeration  of,  86 
chemicals  used  in,  24 
Ammoniacal-silver-magnesium  mixture 
for  uric  acid  tests,  prepara- 
tion  of,  38,  90 

Ammonium  magnesium  phosphate  for 
microscopic  analysis  of  uri- 
nary sediment,  133 
sulphate  solution  for  total  nitrogen 
in  chemical  analysis  of  ur- 
ine, 81 

thiocyanate,   preparation   of,   58 
urate  crystals,  138 
Analysis,  blood  chemical,  28 
general,  of  urine,  102 
of  •whole  blood,  plasma,  and  cells, 

171 

Anesthetic  in  relation  to  blood,  330 
Animal  calorimeters.  350 
Apparatus,    CO2,   showing   air   being 
forced  out  in  tests  for  acido- 
sis of  blood,  66 

Fridericia,  for  determination  of 
carbon  dioxide  in  alveolar 
air,  240 

for  removing  fumes  in  connection 
with  nitrogen  determination, 
48 

Aqueous  solution  of  Napthol  Green 
B  as  a  standard  of  color  in 
cholesterol,  52 


B 

Bacteria,  formula  for  staining,  146 
Basal  heat  production,  353 
Basal  metabolism,  348 
carbon  balance,  361 
energy  balance,  349 
hyperpituitarism    in    relation    to, 

391 
hyperthyroidism    in    relation    to, 

388 
hypopituitarism    in    relation    to, 

390 

hypothyroidism  in  relation  to,  389 
material  balance  of  the  body,  358 
polyglandular  insufficiency  in  re- 
lation to,  386 
respiratory  quotient,  362 
Bcckman  apparatus  for  carrying  out 

cryoscopy,   100 

Benedict's  method  for   determination 

of  total  sulphur  in  urine,  122 

qualitative  solution  for  glucose  test, 

106 
quantitative   estimation   of   glucose, 

106 

volumetric  solution  for  glucose,  106 
Benzidtne  test  for  blood  in  general 

analysis   of  urine,   123 
Betahydroxybutyric    acid,    determina- 
tion of,  114 

determination  of,  in  blood,  77 
Bicarbonate    of    sodium    in    acidosis, 

237,   246 

Bile,  in  general  analysis  of  urine,  123 
Gmelin's  tost  for,   123 
Smith's  test  for,  123 
Blood: 

ace-acetic    acid,    determination    of, 

in,  77 

acetone  in,  determination  of,  77 
acidosis  in,  61 

analysis,  Folin  's  new  methods,  393 
anesthetic  in  relation  to-  changes  in, 

330 

betahydroxybutyric   acid,   determin- 
ation of,  in,  77 


GENERAL   INDEX 


405 


Blood — Cont  'cl 

casts  in  microscopic  analysis  of  uri- 
nary sediment,  127,  129 
changes  in  gout,  263 
chemical   analysis   compared  with 

urinary  analyses,  18 
chemical  methods,  differentiation  of 
cardiac    from    renal    lesions 
by,  289 

chemistry  and  nephritis,  274 
chemistry,  general  consideration  of, 

17 

cholesterol  content  of,  340 
determination  of  urea  by  urease  de- 
composition and  distillation, 
396 
estimation  of  sugar  and  creatinine, 

29 

in  general  analysis  of  urine,  123 
benzidine  test,  123 
guaiac  test,  123 
lipemia,  344 
lipoids,  204 
manner  of  procuring  and  handling, 

25,  26 

pictures  in  gout  and  early  intersti- 
tial nephritis,   268 
pictures  in  gout,  diabetes,  and  ne- 
phritis,  269 

plasma,  saturating  with  carbon  di- 
oxide, 62 
sugar,  28,  260 

and  nephritis,  317 

and   surgery,   necessity    of   blood 

chemical   analysis,   318 
determination  of,  by  Folin's  new 

method,    400 
influence  of  diet,  198 
urea,  303 

withdrawal  of,  25,  26 
amount  needed,  27 
Gradwohl  method,  27 
Bottles    for    use    in    connection   with 
CO2    determination    in    tests 
for  aeidosis  of  blood,  64 
Bock-Benedict    colorimeter,    157 
Body  temperature,  366 


C 

Calcium  carbonate  in  microscopic  anal- 
ysis of  urinary  sediment, 
135,  136 

oxalate  calculi,  141 
oxalate  in  microscopic  analysis  of 

urinary  sediment,  134 
phosphate    in    microscopic    analysis 

of  urinary  sediments,  134 
sulphate  in  microscopic  analysis  of 

urinary  sediments,  135 
Calculating    results    of   total    acetone 

bodies  in  urine,  116 
Calorimeter   for  measurement   of   en- 

ergy,  349 
Carbohydrates,    sugar    content    after 

institution   of,   168 
Carbon  balance,  361 
dioxide  apparatus,  63 

extracting  in   tests  for  aeidosis 

of  blood,  65 

Cardiac     lesions,     differentiation     of, 
from  renal  lesions  by  blood 
chemical  methods,  289 
Casts  in  microscopic  analysis  of  uri- 
nary sediment,  126 
Centrifuge,  placing  in  laboratory,  20 
Centrifuge  tube,  50  c.c.,  28 
Centrifuge  tube  attached  to  suction, 

38 

Characteristic  blood  pictures  in  gout, 
diabetes  and  nephritis,   276, 
277 
Chemicals    used    in    blood    and    urine 

chemistry,   22 

Chemical  balance,  placing  of,  in  labo- 
ratory, 20,  25 
Chemical  blood  bottle,  27 
Cholesterol  and  lecithin,   antagonistic 

action  of,  345 
apparatus  used  in  tests,  24 
chemicals  used  in  tests,  24 
content  of  the  blood,  340 
crystals  of,  139 
determination  of,  50 


406 


GENERAL   INDEX 


Cholesterol — Cont  'd 

estimation   of,  with  Hellige   colori- 
meter, 50 

preparation  of  sample,  50 
Chlorides,  57 
example,  58 
example  of  test,  101 
in  chemical  analysis  of  urine,  test 

for,   101 
CO,  apparatus  for  testing  aeidosis  in 

blood,  63 

C02     apparatus     showing     air     being 

forced  out  in  aeidosis  test,  66 

Color  of  urine  in  general  analysis  of 

urine,   102 

Colorimeter,  Bock-Benedict,  157 
description  of,  148 
Duboscq,  directions  for  using,  156 
Congo  red  used  in  determination   of 

total  nitrogen,  55 
Creatine     and     creatinine,     chemicals 

used  in  solution  of,  23 
Creatinine : 

estimation    in    blood    with    Hellige 

colorimeter,  34 

estimation  of,  by  Folin  method,  398 
in  chemical  analysis  of  urine,  test 

for,   94 

standard  solution  of,  35 
Cryoscopy  of  blood  and  urine,  98 
Cylindroids  in  microscopic  analysis  of 
urinary  sediment,  130 


Definition      of      aeidosis      given      by 

Naunyn,  249 

Description  of  colorimeter,  148 
Determination  for  total  nitrogen,  76 
for  total  solids,  53 
of  alkali  reserve  of  blood  plasma, 

73 

of  precipitate  from  substances  other 
than  acetone  bodies  in  urine, 
114 


Determination — Cont  'd 

of  total  acetone  bodies,  acetone, 
acetoacetie.  acid,  and  hydro- 
butyric  acid  in  one  opera- 
tion, 113 

Development  of  color  in  tests  in 
chemical  analysis  of  urine, 
84 

Development  of  color  in  urea  tests, 
44 

Diabetes,  kidney  changes  in,  228 
phlorizin,  180 

Diacetie  acid  in  general  analysis  of 

urine,  111 
Gerhardt's  test,  111 

Diagnostic  value  of  creatinine  in 
blood  in  nephritis,  283 

Diagram  illustrating  excessive  sugar 
formation  through  retention 
of  glycogen  in  liver,  178 

Diagram  illustrating  normal  sugar 
metabolism,  177 

Diagram  showing  nonutilization  of 
sugar  in  diabetes,  177 

Diet,  influence  of,  on  blood  sugar,  198 
on  respiratory  quotient,  362 

Diseases,  influence  of,  on  energy  bal- 
ance, 357 

Diuresis,  glucose  and  water,  203 

Douglas  bag,  374 

Duboscq  colorimeter,  148 
directions  for  using,  156 


E 


Endocrine  disturbances  in  relation  to 

basal  metabolism,  384 
Energy  balance,  349 

influence  of  age  and  sex,  356 
influence  of  diseases,  357 
methods  of  measuring,  350 
metabolism,   methods   of   calculat- 
ing, 368 

Epithelial  casts  in  microscopic  analy- 
sis of  urinary  sediments,  127, 
128 


GENERAL   INDEX 


407 


Erythroeytes    in    microscopic    analy- 
sis of  sediment  in  urine,  131 
Estimation  of  blood  sugar  with  Hel- 
lige  colorimeter,  table  I,  31 

cholesterol,  table  V,  51 

creatinine    in   blood,   table   II,   34 

creatinine  in  chemical  analysis  of 
urine,  table  VII,  92 

nitrogen,   table  IV,  45 

phenolsulphonephthalein,        table 
VIII,   97 

protein,     in     general     analysis     of 
urine,  109 

total  nitrogen,  table  VI,  82 

uric  acid,  table  III,  40 
Estimation  of  freezing  point  of  blood, 

98 

Ethereal  sulphates  in  the  urine,  Fo- 
lin's  method  of  determining, 
121 

Examining  urinary  sediment  for  sim- 
ple organisms,  145 

Example  of,  estimation  of  nitrogen 
with  Hellige  colorimeter,  45, 
82 

Mohr  method  of  determining  chlo- 
rides, 58 

reading  in  cholesterol,  51 

reading  on  Van  Slyke's  apparatus 
for  acidosis  of  blood,  68 

readings  of  cryoscopy,  99 

result  in  using  standard  solution  of 
creatinine,   35 

sugar  in  blood,  31 

test  for  creatinine  in  chemical  anal- 
ysis of  urine,  94 

test  for  glucose,  106 

test  for  phosphates,  118 

test  for  specific  gravity  of  normal 
urine,   104 


Fasting  and  diet  in  aeidosis,  248 
Fat,  in  relation  to  blood  sugar,  201 
Fatty  casts  in  microscopic  analysis  of 
urinary  sediments,  129 


Fibrin  clots  in  sediments  of  urine, 
following  hematuria,  132 

Finding  over  5.0  mgms.  of  creatinine 
in  blood  denotes  fatal  end  in 
acidosis,"  285 

Folin-Farmer  microchemical  method 
in  total  nitrogen,  56 

Folin-Macallum  reagent  in  uric  acid 
tests,  39,  90 

Folin's  method  for  determination  of 
total  sulphates  in  urine,  119 
method  of  determining  total  acid- 
ity of  urine,  88 
new  methods  of  blood  analysis,  393 

Food  in  relation  to  heat  production, 
352 

Foreign  substances  due  to  contamina- 
tion, microscopic  analysis  of 
urinary  sediment,  132 

Formula  for  preparation  of  sodium 
carbonate,  29 

Fridericia  apparatus  for  determina- 
tion of  carbon  dioxide  in  al- 
veolar air,  240 


Gas-analysis  apparatus,  Haldane,  374 
Gentian  violet  stain  for  staining  bac- 
teria, formula  for,  146 
Gerhard's  test  for  diacetic  acid,  111 
Glucose  and  water  diuresis,  203 
in  general  analysis  of  urine,  106 
ingestion,  plasma  and   urine   sugar 

as  influenced  by,  206 
qualitative  test  for,  106 
qualitative  solution  for,   106 
quantitative  estimation.1  of,  106 
removal  of,  112 
tolerance,  201 

tolerance  tests,  result  of,  199 
volumetric  solution  for,  106 
Janney  's  studies  of  formations  from 

body  protein,   179 
Gmelin's  test  for  bile,  123 


408 


GENERAL   INDEX 


Gout,   advisability   of   blood   chemical 
analysis  in  dealing  with  sus- 
pected cases,  269 
amount   of  uric  acid  under  normal 

conditions,  263 

differentiating  gout  from  rheuma- 
tism  and   other   joint   affec- 
tions, 266 
increase  in  uric  acid  concentration, 

265 
repeated     examinations     necessary, 

265 

uric   acid   can   be    found   in   blood 
without  gouty  symptoms,  267 
Graduated  centrifuge  tube  used  in  de- 
termining chlorides,  57 
Graduated  sugar  tube,  29 
Gradwohl's    tourniquet,    26,    27 
Granular  casts  in  microscopic  analy- 
sis of  urinary  sediments,  126, 
127 

Guaiac  test  for  blood  in  general  anal- 
ysis of  urine,  123 

H 

Haldane  gas-analysis  apparatus,  374 
Hellige  colorimeter: 

choice  for  practical  work,  the,  148 

description  of,  149 

estimation    of    blood    sugar    with, 

table  I,  31 

cholesterol  with,  table  V,  51 
creatinine  in  blood  with,  table  II, 

34 
creatinine  in  chemical  analysis  of 

urine,  table  VII,  92 
nitrogen,  table  IV,  45 
phenolsulphonephthalein,  table 

VIII,  91 
protein,    in    general    analysis    of 

urine,  table  X,  110 
total  nitrogen,  table  VI,  82 
uric  acid,  table  III,  40 
optical  arrangement  of  window  in, 

153 

representations    of,    149,    150,    151, 
152 


Henderson  and  Palmer's  experiments 
showing  magnitude  of  alkali, 
248 

Hippuric  acid  crystals,  140 

Hyaline  casts  in  microscopic  analysis 
of  urinary  sediments,  127, 
128 

Hydrogen-ion  concentration  of  the 
blood,  Marriott,  Levy,  and 
Rowntree's  method  of  deter- 
mining, 68,  238 

Hypercholesterolemia,   341 

Hyperpituitarism,  391 

Hyperthyroidism,   388 

Hypopituitarism,   390 

Hypothyroidism,    ?,89 


Indiean,  Obermayer's  test  for,  117 

Indicator,  ferric  alum  in  determina- 
tion of  chlorides,  57 

Iridigo-carmin  test  for  kidney  effi- 
ciency, 97 

Inorganic  sulphates  in  urine,  Folin's 
method  for  determination  of, 
120 

Interpretation  of  results  from  Mar- 
riott, Levy,  and  Eowntree's 
experiments  in  acidosis  of 
blood,  77,  238 

Installation  of  blood  and  urine  labo- 
ratory, 19 

Introduction  of  alkalies,  method  of, 
234 


Janney  technic  in   cases   of  phlorizin 
diabetes,  180 


K 


Kidney  changes  in  diabetes,  228 
efficiency,    indigo-carmin    test    for, 

97 

function  in   operative   risk,   318 
tuberculous,  treatment,  144 


GENERAL   INDEX 


409 


Kjeldahl  apparatus  showing  conden- 
ser in  total  nitrogen,  55 

Kjeldahl  flask  for  determination  of 
total  nitrogen,  54 


Laboratory,   blood   and  chemical,   19 

installation   of,   19 

selection  of  room,  20 

views  of,  21,  22,  23 
Leucine  crystals,  140 
Lipemia,   344 
Lipoids,  59 
blood,  204 

M 

Marriott,  Haessler  and  Rowland's 
method  in  estimating  acido- 
sis  in  nephritis,  253 
Marriott  and  Rowland's  method  of 
estimating  acidosis  in  ne- 
phritis, 252 

Marriott,  Levy,  and  Eowntree's  meth- 
od of  the  hydrogen-ion  con- 
centration of  the  blood: 
apparatus   required,   73 
comparison  of  tubes  with  stand- 
ards, 71 

controls  of  method,  71 
preparation   of   sacks,   70 
preparation    of    standard    colors 

(according  to  Sorenson),  69 
salt  solution  used  in  method,  70 
technic  of  method,  71 
Material  balance  of  the  body,  methods 

of  measuring  output,  358 
Metabolism,  348 

influence    of,    on    respiratory    quo- 
tient,   363 

Method  of  determination  in  alkali  re- 
serve ..of   the   blood   plasma, 
75 
Method  of  introduction  of  alkalies  in 

acidosis,  234 

Method  of  washing  sacks  used  in  aci- 
dosis tests,  75 


Microburner,  47 

Microscopic  analysis  of  urinary  sedi- 
ment: 

centrifuge  for,  125 
conical  centrifuge  tube  for,  125 
organized  sediments,   126 
casts,   126 
blood,  127 
epithelial,   127 
fatty,  129 
granular,   126 
hyaline,  127 
pus,  130 
waxy,  129 
cylindroids,   130 
erythrocytes,    131 
fibrin,  132 

foreign    substances    due    to    con- 
tamination, 132 
spermatozoa,  132 
tissue  debris,  132 
urethral  fragments,  132 
pathological  condition  in  which  leu- 
cine  and  tyrosine  have  been 
found,  140 
pathological     conditions     in    which 

uric  acid  is  found,  137 
preparation  of  sediment,  125 
unorganized  sediments,  132 

ammonium      magnesium      phos- 
phate,  133 

calcium  carbonate,  135 
calcium  oxalate,  134 
calcium  phosphate,  134 
calcium  sulphate,  135 
cholesterol,  139 
cystine,  139 
hippuric  acid,   140 
leucine   and   tyrosine,    140 
urates,  139 
uric  acid,  137 
urinary  calculi,  141 
Modification    of    test    for    nonprotein 
nitrogen  to  serve  for  blood 
estimations,  47 


410 


GENERAL   INDEX 


Mohr  method  in  determining  chlo- 
rides, 58 

Murexide  test  for  urinary  calculi  in 
microscopic  analysis  of  uri- 
nary sediments,  142 

Muscular  exercise,  367 

N 

Napthol   Green   B  _as   a   standard   of 

.  color  in  cholesterol,  52 
Nephritis : 

Ambard's  coefficient,  296 

blood  chemical  figures  most  trust- 
worthy, 282 

blood  sugar  in,  317 

blood  picture  of  gout,  diabetes,  and 
nephritis,  276,  277 

cases  of  thermic  fever,  reports  of, 
285 

death  rate  lower  in  surgery  after 
treatment  for  kidneys,  319 

importance  of  creatinine  in  routine 
blood  chemical  analysis  in 
connection  with  chronic  ne- 
phritis, 278 

McLean's  modification  of  Am- 
bard's coefficient,  302 

phenolsulphonephthalein  in,  281 

scale  of  degree  of  impairment  of 
renal  function  as  indicated 
by  the  tests  employed,  300 

table  of  blood  and  urine  findings  in 
thermic  fever,  286 

table  of  uric  acid,  nitrogen,  and 
creatinine  of  blood  in  inter- 
stitial nephritis,  284 

test  meal  for  renal  function  and 
Ambard  's  coefficient,  296, 
297 

total  nitrogen,  274 

valuable  report  of  unusual  case  of 
chronic  interstitial  nephritis, 
287 

value  of  Ambard's  coefficient,  301 

value  of  Geraghty  and  Kowntree 
test,  280 


Nessler's  solution,  preparation  of,  44 
Nessler's  solution  for  total  nitrogen, 

47 

Nitric  acid  ring  test  for  albumin,  108 
Nitrogen,  estimation  of,  with  Hellige 

colorimeter,   82 
Nonprotein   nitrogen,    chemicals    used 

in,  24 

Nonprotein,    modification    of    test    to 
serve  for  blood  estimates,  47 
Normal  urine,  appearance  of,  102 
odor  of,  103 
reaction,  104 
specific  gravity,  104 
solids,  104 
Normal  values  of  energy,  353 


Obermayer 's  test  for  indican,  117 

Odor  of  normal  urine,  103 

Optical    arrangement    of    window    of 

colorimeter,  153 
Organized    sediments    in    microscopic 

analysis  of  urinary  sediment, 

126 


Pathologic  conditions  in  which  crys- 
tals are  found  in  the  urine, 
134 

Pathologic  conditions  in  which  ery- 
throcytes  are  found  in  uri- 
nary sediment,  131 

Pathologic  conditions  in  which  excre- 
tion of  potash  is  increased, 
118 

Pathologic  conditions  in  which  leucine 
and  tyrosine  hayc  been  found, 
140 

Pathologic  conditions  in  whicli  uric 
acid  is  found,  137 

Phenol  ether  instead  of  caprylic  al- 
cohol, 64 

Fhenolsulphonephthalein : 
apparatus  used  in,  24 
chemicals  use  in,  24 


GKNKRAL    INDKX 


411 


Phenolsulphonephthaloin — Cont 'd 
estimation  of,  97 
example  of  test,  97 
graduated  syringe   used   for  injec- 
tion of,  96 

preparation  of  solution,  95 
procedure,  95 
standard  preparation,  96 
use  of,  in  nephritis,  281 
Phlorizin    diabetes,    Janney's    experi- 
ments, 180 
Phosphates : 

accessory  solution  for,  118 
example  of  test  for,  118 
pathologic  condition    in    which    the 

excretion  is  decreased,  118 
pathologic    condition    in    which    th? 

excretion  is  increased,  118 
Picramic  acid  solution,  standard,  30 
Plasma  and  urine  sugar  as  influenced 

by  glucose  ingestion,  206 
and  urine  sugar  in  relation  to  eat- 
ing, 206 
sugar,  201 
Polyglandular  hyperactivity,   387 

insufficiency,  385 

Preparation    of    Folin-Macallum    re- 
agent in  uric  acid  test,  39 
Preparation    for    indicator    used    in 
chlorides    in    chemical    anal- 
ysis of  urine,  101 

Preparation  of  phosphate  mixture  in 
determination    of    alkali    re- 
serve of  blood  plasma,  73 
Preparation  of  sacks  for  test  in  acido- 

sis  of  blood,  70 

Preparation   of  salt  solution  for  de- 
termination of  alkali  reserve 
of  blood  plasma,  74 
Preparation     of     sodium     carbonate, 

formula  for,  29 

Preparation  of  sodium  hydroxide  in 
total  nitrogen  determina- 
tions, 56 


Preparation  of  sodium  standard 
colors  for  comparison  of 
color  in  carrying  out  tests 
for  acidosis  in  blood,  69 

tests  for  acidosis  with  pure  chol- 
esterol, 51 

tests  for  acidosis  uric  acid,  stand- 
ard solution,  90 

Producing  acidosis  in  dogs  for  experi- 
mental purposes,  250 
Protein  ingestion,  202 

Janney's  studies  from  glucose  for- 
mation from  body  protein, 
180 

quantitative  estimation  (Purdy), 
109 


Qualitative  test  for  glucose,  Bene- 
dict's, 106 

Quantitative  estimation  of  glucose, 
Benedict's,  106 

Quantitative  estimation  of  protein 
(Purdy),  109 

E 

Reaction  of  normal  urine,  104 
Reagents  for  Folin's  new  methods  of 

blood  analysis,  395 
Removal  of  glucose  and  other  factors 

in  urine,  112 

Renal  diabetes  in  pregnancy,  191 
function,  203 

methods  for  investigating,  332 
lesions,     differentiation     of,     from 
cardiac     lesions     by     blood 
chemical  methods,  289 
test  meal,  287 
threshold,  202 
Representation  of  Hellige  colorimeter, 

149 

Respiration  calorimeter,  359 
Respiratory  exchange,  magnitude  of, 

365 

Respiratory  quotient,  392 
influence  of  diet  on,  362 


412 


GENERAL   INDEX 


Ecspiratory   quotient — Cont  'd 

influence  of  metabolism  on,  363 
Robert's  test  for  albumin,  109 
Eobert's  reagent  for  nitric  acid  test 

for  albumin,  109 
Eoux's  blue,   formula  for,  145 


Salt  solution  used  in  method  of  Mar- 
riott,   Levy,    and    Eowntree 
for  acidosis  in  blood,  70 
Saturating  blood  plasma  with  carbon 

dioxide,  62 
Sediments  in  microscopic  analysis  of 

urine,  125 
examining    for    simple    organisms, 

145 

organized  sediments,   126 
unorganized  sediments,  132 
Sex,  influence  of,  on  energy  balance, 

356 
Solutions    required    in    determination 

of   acetone,   112 
Smith's  test  for  bile,  123 
Sodium  hydroxide,  preparation  of,  56 
Solids  of  normal  urine,  105 
Solution   of  ammonium  sulphate,   42 
Solution,  Nessler's,  44 
Specific    dynamic    action    of    food- 
stuffs, 352 

Specific  gravity  of  normal  urine,  104 
Spermatozoa   in   microscopic    analysis 

of  urinary  sediment,  132 
Spinal    fluid,    chemistry    of,    as    com- 
pared with  blood  chemistry, 
306 

Staining  of  bacteria  in  urine,  144 
bacillus  tuberculosis,  144 
bacillus  typhosus,  144 
carbol  gentian  violet  for  modifica- 
tion of,  Gram  method,  146 
diagnosis  of  tuberculosis  from  uri- 
nary sediment  important,  144 
Eoux's  blue  for  simple   organisms, 

145 
test  for  bacillus  tuberculosis,  144 


Standard  for   comparison,   354 
Standard  solutions: 

ammonium  thiocyanate,  101 
bichromate  of  potash,  55 
phenolsulphonephthalein,  96 
silver  nitrate,  101 
sodium  carbonate,  29 
uric  acid,  90 
Sugar    content,    after    institution    of 

carbohydrates,  168 
in  fasting  persons,  167 
excreted,  character  of,  203 
in  blood: 

advisability  of  beginning  blood 
chemical  analysis  at  once 
with  sugar  and  ereatinine  be- 
cause of  their  quick  dete- 
rioration, 26 

best  time  to  test  for,  225 
cases  in  literature,  193 
diabetes  mellitus,  224 
estimations  of,  with  Hellige  color- 
imeter, 31 

example  of  readings,  31 
graduated  sugar  tube,  29 
Gradwohl  data  on  blood  and  urine 

cases,  225 

Ostwald  pipette  in,  29 
picramic  acid  solution  in,   30 
renal  diabetes  in  pregnancy,  191 
saturated  solution  of  sodium  car- 
bonate, 29 
sugar  tube  immersed  in  beaker  of 

water  in  test,  30 
plasma,  201 

Sulphates,  ethereal,  121 
inorganic,  in  urine,  120 
in  urine,  119 
Sulphur  in  urine,   Benedict's  method 

for  determining,  122 
Surgery,  blood  chemistry  and,  318 


Table  for  estimation  of  blood  sugar 
with  Hellige  colorimeter, 
table  I,  31 


GENERAL   INDEX 


413 


Table  for  estimation — Cont'd 
cholesterol,  table  V,  51 
creatinine  in  blood,  table  II,  34 
creatinine   in  chemical   analysis   of 

urine,  table  VII,  92 
nitrogen,  table  IV,  45 
phenolsulphonephthalein,    table 

VIII,  97 
protein,     in     general     analysis     of   ! 

urine,  table  X,  110 
total  nitrogen,  table  VI,  82 
uric  acid,  table  III,  40 
Table  showing  blood  pictures  of  gout 
and  early  interstitial  nephri- 
tis, 268 

scale    of   degree    of   renal   function 

by   tests  employed   in  blood 

chemistry  and  nephritis,  300 

Technic  of  Marriott,  Levy,  and  Rown- 

tree,  71 

Temperature  of  the  environment,  366 

Test  for  acetone  bodies  in  urine,  114 

meal  for  renal  functions  in  blood 

chemistry      and      nephritis, 

296,  297 

with  guinea  pigs  for  renal  tuber- 
culosis, 145 
Tests  for  bile  in  general  analysis  of 

urine,  123 

Tissot  spirometer,  372 
Tissue  debris  in  microscopic  analysis 

of   urinary   sediments,   132 
Titration  of  precipitate  in  urine  with 

Gooch  crucible,   114 
Toluene    satisfactory    for    preserving 

urine  for  test  purposes,  105 
Total  acidity,  Folin's  method  in  cal- 
culation of,  88 
Total  nitrogen: 

determination,  80 
digestion  rack,  55 
estimation  of,  with  Hellige's 

colorimeter,  81 
example,  81 

Folin-Farmer    microchemical 
method,   56 


Total    nitrogen — Cont  'd 
Kjeldahl  apparatus,  55 
Kjeldahl  flask,  54 
Total  solids: 

calculation  in,  53 
determination,  53 
weighing  bottle  for,  53 
Total     sulphates     in     urine,     Folin's 

method  of  calculating,  119 
Total    sulphur    in    urine,    Benedict's 

method  of  calculating,  122 
Tourniquet,     Gradwohl's     for     blood 

withdrawal,  26,  27 

Tungstic  acid  as  precipitant  in  blood 
analysis,  393 


U 


Unorganized  sediments  in  microscopic 
analysis     of     urinary     sedi- 
ments, 132 
Urates,  139 
Urea,    apparatus,    arrangement    for, 

22 
apparatus,    set    up    and    connected 

with  suction,  43 
blood,  303 

determination  of,  by  urease  decom- 
position and  distillation,  396 
development  of  color,  44 
estimation  of  nitrogen  in,  with  Hel- 

lige  colorimeter,  45,  82 
result,  84 
Urea  N.,  apparatus  used  for,  22 

chemicals  used  in,  22 
Urease,  where  obtainable,  42 
Urethral    filaments,    in    microscopical 
analysis     of     urinary     sedi- 
ments, 132 
Uric  acid: 

and  urate  calculi,  141 
apparatus  used  in,  23 
chemicals  used  for,  23 
crystals  of,  137 

estimation   of,  by  Folin's  meth- 
od, 398 


414 


GKNERAL   INDEX 


Uric  acid — Cont  'd 

solution,  preparation  of,  39 
tost  for,  90 

urea  nitrogen,  and  creatinine  of 
blood   in   interstitial   nephritis, 

284 
Urinary  analyses  compared  with  blood 

analyses,  18 
calculi,  141 

murexide  test  for,  142 
table  illustrating,  143 
Urinary   sediments: 

microscopic  analysis,  125 
organized,   126 
preparation   of,   125 
unorganized,  132 

Urine : 

acetone  bodies  in,   111 

and  blood  findings  with  various 
diets,  211 

blank  determination  of  precipitate 
from  substances  in  other 
than  acetone  bodies,  114 

color  of  normal,  102 

example  of  determination  of  spe- 
cific gravity,  104 

Long's  coefficient,  105 

pathologic  conditions  which  cause 
decrease  of  output  of,  102 

pathologic  conditions  which  cause 
increase  of  output  of,  102 

reaction  of  normal,  104 

separate  day  and  night  urine  in 
pathologic  cases,  105 

specific  gravity  and  solids,  104 

sulphates  in,  119 


Urine — Cont  'd 

table  of  color,  cause  of  coloration 

and     pathologic     conditions, 

103 

total  acidity  of,  88 
transparency  of,  102 
volume,  102,  203 


Value  of  toluene  for  preserving  urine 

for  testing,   105 
Van  Slyke  'a  carbon  dioxide  apparatus, 

arrangement  of,  21 
Van    Slyke  'a   method    for    determina- 
tion of  carbon  dioxide  com- 
bining power  of  blood  plas- 
ma, 61 

apparatus    showing    operator    satu- 
rating    blood     plasma     with 
carbon  dioxide,  62 
CO2  apparatus,  63,  67 
CO2   apparatus    showing    air    being 

forced  out,  66 

extracting  carbon  dioxide,  65 
dropping  bottles  used  in,  64 
Volhard-Arnold  method   of   determin- 
ing chlorides,  57 
Volume  of  urine  in  general  analysis, 

102 

Volumetric   flask   used   in    developing 
color  in  uric  acid  test,  39 

W 

Washing  sack  used  in  tests  for  acido- 

sis,  method  of,  75 
Waxy    casts    in    microscopic    analysis 

of  urinary  sediments,  129 
Weighing  bottle  for  total  solids,  53 


AUTHORS  INDEX 


ABDERHALDEN,  32 

ACKROYD,  272 

ADDIS  and  WATANABA,  301,  303,  333 

ADLER  and  EAGLE,  263 

AGNEW  32,  49,  332 

ALBERTONI  and  PISENTI,  230 

ALDEHOFF,  176,  186,  189,  193,  225 

ALLEN,  32,  248 

ALLEN,  WISHART,  and  SMITH,  196 

AMBARD,  230,  296,  297,  332,  336 

AMBARD  and  WEILL,  231 

ARMANNI,  228 

ARTHAUD,  176 

ASCHER,  186 

AUSTIN  and  MILLER,  49 

AUTENRIETH  and  FUNK,  52 

AUTENRIETH   and   KOENIGSBERGER,    149 

B 

BACMEISTER  and  HENES,  341 

BAETJER,  335 

BANG,  32,  52,  173,  317 

BARKER,  237 

BAUMANN,  278 

BEDDARD,  PEMBERY,  and  SPRIGGS,  79 

BEER,  324 

BENEDICT,    106,    121,    163,    209,    219, 

337,  354 

BENEDICT  and  HITCHCOCK,  41 
BENEDICT  and  LEWIS,  17,  171,  230 
BERGER  and  TSUCHIYA,  345 
BERNARD,  182 
BERTRAND,  32 

BIACH,  KERL  and  KABLER,  312 
BIERRY,  32 
BLOCK,  272 

BLOOR,  50,  52,  59,  342,  346 
BLOOR  and  KNUDSON,  340 
BLOOR  and  MACPHERSON,  344 
BLUM,  185 
BLUMENTHAL,  156 
BOCK  and  BENEDICT,  49 
BOB,  32 
BOENNIGER,  346 
BOENNIGER  and  TACHAN,  193 
BOOTHBY  and  PEABODY,  79,  244 
BRUGSCHE    and    SCHITTENHEIM,    263, 

271 

BURIAN  and  SCHUR,  272 
BUTTE,  176 


CAMMIDGE,  173 

CANTIERI,  341,  342 

CAONAL,  311 

CATAIGNE  and  WEILL,  309 

CATHELIN,  333 

CHACE,  288 

CHACE   and  MYERS,  35,  41,  46,  283, 

301 
CHAUFFARD,    LAROCIIE    and    GRIGAUT, 

341,  347 
CHELLE,  32 
COMBE  and  LEVI,  46 
CONTEJEAN,  188 
COOKE,   EODENBAUGH,   and    WHIFFLE, 

338 

COOLEN,  188 

CRAMER  and  KRAUSE,  185 
CREMER  and  BITTER,  188 
CUMMINGS  and  PINESS,  173,  334 
CULLEN  and  ELLIS,  307 
GUSHING,  309 

D 

DAKIN  and  DUDLY,  56 
DENIS,  341,  342,  347 
DENIS  and  AUB,  184,  185 
DE  LANGEN,  193 
DE  EINZI,  176 
DORNER,  32,  278 
DOUGLAS,  374 
Du  Bois,  354,  366 
Du  SABLON,  181 

E 

EBSTEIN,  228 
ECKHARD,  183 
EHRLICH,  230 
EPPINGER,  33 

EPPINGER,  FALTA  and  EUDINGER,  18 
EPSTEIN,  32 

EPSTEIN  and  EOTHSCHILD,  347 
ERBEN,  347 
ERLANDSEN,  189 


FALTA,  33 

FANDERN,  32 

FARR  and  AUSTIN,  32,  49 

FARR  and  KRUMBHAAR,  32,  49 

FARR  and  WILLIAMS,  4? 

FAUST  and  TALLQUIST,  345 


415 


416 


AUTHORS   INDEX 


FEHLING,  195,  225 

FEHLING  and  PURDY,  106 

FINE,  266,  269 

FINE  and  CHACE,  41 

FISCHER,  327 

FISCIIL,  342 

FITZGERALD,  259 

FITZ,  49,  228,  231 

FLATOW,  32 

FOLIN,  17,  32,  35,  49,  119,  163,  195, 

275,  304,  337 
FOLIN  and  DENIS,  17,  32,  35,  41,  46, 

49,  56,  263,  267,  269,  278,  279 
FOLIN,  DENIS,  and  SEYMOUR,  32,  49, 

332 

FOLIN  and  FARMER,  49,  56,  80 
FOLIN,  FARMER  and  DENIS,  332 
FOLIN,  KARSNER  and  DENIS,  32 
FOLIN  and  LYMAN,  49 
FOLIN  and  MACALLTJM,  39,  41,  90 
FOLIN  and  PETTIBONE,  46 
FOLKNER  and  JOSEPH,  97 
FOSTER,  35,  46,  49,  160,  181,  182,  191, 

196,  331,  332 

FRANK,  32,  52,  164,  165,  173,  219,  325 
FRANK  and  BRETSCHNEIDER,  169 
FRANK  and  ISAAK,  32 
FRASER  and  GARDNER,  340 
FRIDERICIA,  241 
FROMENT,  309 
FROTIIINGHAM,  49,  256 
FROTIIINGHAM,      FITZ,      FOLIN,     and 

DENIS,  32,  280,  320 
FROTIIINGHAM  and  SMILLIE,  49 


GAGLIO,  176 

GARDNER  and  MCLEAN,  32 

GARROD,  263 

GERAGIITY  and  BOWNTREE,   148,  280, 

327 

GERHARDT,  111 
GEYELIN,  184 
GILBERT,  32 
GLEY,  176 
GMELIN,  123 
GOODMAN,  340 

GORHAM  and  MEYERS,  340,  343 
GRADWOHL,  25,  26,  164,  187,  306 
GRADWOHL  and  BLAIVAS,  47,  49,  80 
GRADWOHL  and  POWELL,  289 
GRADWOHL  and  SCHERCK,  319 
GRADWOHL  and  SCHISLER,  285 
GRAHA.M,  184,  193 
GREENWALD,  49,  347 
GRIPSBAU,  32 
GRIGAUT,  52 
GULICK,  49,  56 


H 


32 


IlALDANE,  230,  259,  374 

HALL,  273 

HALLIBURTON,  102,  306 

HALSEY,  287 

HAMMANN  and  HIRSCHMAN,  160,  174 

HANES,  52 

HARDING  and  WARENEFORD,  49 

HARLEY,  176 

HAWK,   32,   128,   129,   136,   138,   139, 

141 

HECHT-GRADWOHL,  226 
HEDON,  176 
HELLER,    108,   142 
HENDERSON,   69,    232,   233,   247,   256, 

259,  327 

HENDERSON  and  PALMER,  248,  252 
HENES,  52,  341,  347 
HENSEL  and  WEIL,  136 
HERTER,  183 

HERTER  and  EICIIARDS,  186 
HERTZ,  49 
HIGGINS,  79,  244 
HIGGINS  and  MEANS,  79 
HIGGINS,  PEABODY,  and  FITZ,  79 
HIRSCHSTEIN,  272 

HOEBER,  164 
HOHLWEG,  49 
HOLLTNGER,  164,  173 

HOPKINS,  32,  173,  310,  317 

HOPKINS  and  JONES,  49,  332 

HORNER,  241 

HOWLAND,  246,  256 

HOWLAND,  HAESSLER,  and  MARRIOTT, 

253 
HOWLAND  and  MARRIOTT,  76,  79,  233 


JACOB,  311 

JAKSCH,  130 

JANNEY,  173,  180 

JAVAL  and  ADLER,  309 

JAVAL  and  BOYET,  309 

JONAS  and  AUSTIN,  301 

JOSLIN,  32,  59,   163,  182,   191,  246 

K 

KAPLAN,  312     ' 
KAPSEMAR,  98 

KARSNER  and  DENIS,  32,  49 
KAUFMAN,  272 
KAUFMAN  and  MOHR,  273 
KJELDAHL,  155 
KLEEN,  225 
KLEMPERER,  173,  188 
KLERCKER,  275 
KOLISH,  188 


AUTHORS   INDEX 


417 


KOPETZKY,  310 
KORANYI,     98 
KOWARSKY,    173 

KRISTELLER,  46 

KRUGER  and  SCHMID,  272 

KUELZ,  178 

KUELZ  and  WRIGHT,  188 

KUEMMEL,  99 

KULLMANN,    345 
KUMAGAVA   SUTO,   32 
KUTSCHMER,   183 


LANCEREAUX,  176 

LEPINE,  164,  166,  176,  188 

LEVENE,  188,  208 

LEVY  and  BOWNTREE,  79 

LEVY,  EOWNTREE,  and  MARRIOTT,  79, 

333 

LEWIS,  333 

LEWIS  and  BENEDICT,  32,  195,  337 
LEWIS  and  MOSENTHAL,  192 
LEWIS,  BYFFEL,  and  others,  252 
LIEFMANN  and  STERN,  32 
LIFSCHUTZ,  52,  340 
LJUNGDAHL,  272 
LOEB,  164 

LOEFFLER,   146 

LOWY,  49 

LUSK,  180,  188 

LYTTKENS  and  SANDGREEN,  164 


M 

MACLEOD,  32,  348,  368 

MAGNUS-LEVY,  265 

MAGUITZ,  32 

MALLORY,  272 

MARFAN,  TOBLER,  and  HELMHOLZ,  235 

MARKUSE,  176,  188 

MARRIOTT,  71,  73,  77,  79,  232,  236,  319 

MARRIOTT  and  HAESSLER,  253 

MARRIOTT  and  HOWLAND,  252 

MARRIOTT,  LEVY,  and  EOWNTREE,  68, 

79,  2-38 

MARSHALL,  46,  337 
MARSHALL  and  DAVIS,  32,  307 
M.\  si  NO,  164,  169 
MAYER,  187 

McCLENDON,   79 

McCLENDON  and  MAGOON,  79 
McCLURE  and  PRATT,  269,  272 
MCLEAN,  318,  333 
McLEAN  and  SELLING,  32,  49,  298 
MCLEAN  and  VAN  SLYKE,  230 

McLESTER,   264 
McPHEDRAN,    345 


MEANS,  383 

MELLANBY,  278 

MENDEL  and  LYMAN,  272 

MESTREZAT,  311 

METZGER,  186 

MICHAELIS  and  EONA,  32,  164,  165 

MlCHAND,    49 

MINKOWSKI,  176,  188,  272 

MITCHELL  and  ECKSTEIN,  64 

MOECKEL  and  FRANK,  32 

MOHR,  57,  179 

MORITZ  and  PRAUSNITZ,  188 

MORRIS,  272 

MOSENTHAL,  49,  317,  332,  338 

MOSENTHAL  and  LEWIS,  297,  298,  301 

MUELLER,   347, 

MULLER,  32 

MURPHY,  MEANS  and  AUB,  383 

MYERS  and  BAILEY,  32,  171,  172,  317, 
337 

MYERS  and  DuBois,  382 

MYERS  and  FINE,  31,  32,  34,  35,  40, 
41,  45,  49,  51,  53,  56,  57,  80,  82, 
86,  92,  97,  106,  266,  267,  275,  278 

MYERS,  FINE,  and  LOUGH,  267 

MYERS  and  GORHAM,  52 

MYERS  and  LOUGH,  35,  283,  332 

MYERS,  LOUGH  and  CHASE,  287 


N 

NAKAGAWA,  336 
NAUNYN,  33,  173,  221,  249 
NAURATZKI,  310 
NEUBAUER,  33,  317 
NEUMANN,  46 


OBERMAYER,  117 
OGDEN,  133,  141 
OLIVIERI,  46 


PALLADIN  and  WALLENBURGER,  278 

PAVY,  33,  188 

FEABODY,  79 

PEARCE,  33,  368 

PEPPER  and  AUSTIN,  40,  301,  334 

PEYER,  127,  129,  130,  138 

PLASS,  49 

PLESH,  79,  230,  244 

PLUMMER,  DICK  and  LIEB,  272 

POLLAK,  186,  187,  272 

PRATT,  264,  265 

PRIBRAM,  49 

PtJRDY,  109 

PURJEZ,  173 


418 


AUTHORS   INDEX 


REACH,  265 
REALE,  176 

REICHER  and  STEIN,  33 
REMOND,  176 

RlESSER,    278 

ROBERT,  109 

ROLLY  and  OPPERMANN,  33,  165,  317 

RONA,  169 

RONA  and  DOBLIN,  164 

RONA  and  MICHAELIS,  172 

RONA  and  TAKATASCHI,  169 

ROOSENBLOOM  and  GIES,  340 

ROSE  and  COLEMAN,  46 

ROTHSCHILD  and  FELSEN,  344 

ROTHSCHILD  and  ROSENTHAL,  344 

ROWNTREE,  256,  260 

ROWNTREE  and  GERAGHTY,  95,  332 

S 

SANBORN,  383 
SANDMEYER,  176 
SCHABAD,  176 
SCHAPIRO,  345 
SCHIFF,  183 

SCHIROKAUER,    33,    164 

SCHISLER,  285,  289 

SCHULTZ  and  PETTIBONE,  49 

SCHMIDT,  52,  341,  347 

SCHWARZ,  186,  189 

SCHWARTZ  and  McGiLL,  332 

SCOTT,  33 

SEELIG,  176 

SELLARDS,  333 

SHAFFER,  33,  111,  195,  278 

SICARD  and  ROUSSEAU,  311 

SIEBECK,  46 

SILVESTRINI  and  NESTRI,  311 

SMITH,  123 

SOPER  and  GRANAT,  309 

SORENSON,  68,  72 

STENSTROM,  33 

STILLING,  33 

STILLMAN,  79 

STROUSE,  33,  173 


TACHAU,  33,  164,  165,  167 
TACHAU  and  FLESCH,  184 
TAKATASCHI,  33 


TALLQUIST,  345 

TAYLOR  and  HUTTON,  33,  49,  222,  224 

TAYLOR  and  LEWIS,  49 

THIROLOIX,  176 

TILESTON  and  COMFORT,  33,  49,  332, 

338 
TRAMBUSTI  and  NESTI,  230 

U 

ULLMAN   and   SPONAGEL,   64 
UMBER  and  RATZLOFF.  271 


VAN  SLYKE,  59,  76,  79,  237,  241,  256 

260 

VAN  SLYKE  and  CULLEN,  46,  302,  308 
VAN  SLYKE  and  FITZ,  77,  79,  111 
VELICH,  187 
VOGT,  265 

VOLHARD- ARNOLD,  57 
VON  HESS,  33 
VON    HOOGENIIUYZE   and  VERPLOEGH, 

275 

VON  JAKSCH,  266,  310 
VON  MERING,  188 
VON   MERING   and   MINKOWSKI,    176, 

178 
VON  NOORDEN,  33,  176,  179,  180,  266 

W 

WALKER   and   FROTHINGHAM,   244 
WALPOLE,  69 
WATJOFF,  346 
WEILAND,  33 
WE-INTRAUB,  176 
WEISS,  41,  272 
WESTON,    52 
WESTON  and  KENT,  52 
WIDAL,  309,  347 
WIDAL,  WEILL,  and  LAUDAT,  341 

WlNDAUS,  52 

WHITNEY,  260 

WOLF  and  SHAFFER,  275 

WOODS,  35,  49 

WOODYATT,  188,   223,   256,  258 

WOODYATT,  SANSUM  and  WILDER,  33, 


ZUNTZ,  188 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


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001286136    5 


